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http://www.archive.org/details/lecturesongenera1912defo 


DR.  HORACE  WELLS. 

Discoverer  of  Siiroir-;i]   AnBcsthesia. 

(Nevius) 


LECTURES 


ON 


General  Anaesthetics 


IN 


Dentistry 


Advocating  Painless  Dental  Operations 

By  the  use  of 

Nitrous  Oxid,  Nitrous  Oxid  and  Oxygen,  Chloroform, 
Ether,  Ethyl  Chloride  and  Somnoform 


BY 

WILLIAM  HARPER  DeFORD,  A.M.,  D.D.S.,  M.D. 

Dean  and  Professor  of  Oral  Pathology  and  Ansesthetics,  Drake  Uni- 
versity College  of  Dentistry;  Late  Professor  of  Oral  Patholoev 
Surgery  and  Hygiene.  College  of  Dentistry,  State  University  of 
Iowa;  Formerly  Professor  of  Oral  Pathology,  Drake  Univeraitv 
College  of  Medicine;  Member  National  Dental  Association:  Member 
and  Ex-President  Iowa  State  Dental  Society;  Member  The  New 
York  Society  of  Anaesthetists;  Honorary  Member  Missouri  Kan- 
sas,  South  Dakota  and  Colorado    State    Dental    Societies     and    the 

Rn.^rt°"„'f  ^'"■l''7t^°^  ^f"^"*'  ^^^'^^^'^^      Ex-President      Iowa     State 
Board  of  Dental  Examiners,  etc.,  etc. 


SECOND  EDITION 
WITH  ILLUSTRATIONS 

LEE  S.  SMITH  &  SON  COMPANY 

PUBLISHERS 

Pittsburgh,  Pa. 

1912 


Copyrighted,  1912, 

By 

LEE   S.   SMITH  &  SON  CO. 


DEDICATION 

To 

JESSIE  RITCHEY  DeFORD,  D.D.S., 

In  recognition  of  her  ability  as  a  skilled  anaesthetist 

and  valued  co-laborer,  I  dedicate  this  volume. 


PREFACE  TO   SECOND   EDITION. 

The  fact  tliat  a  book  is  well  received  is  more 
gratifying  to  an  author  than   financial   returns. 

The  first  edition  of  this  book  was  exhausted  last 
summer,  and  since  that  time  there  have  been  more 
inquiries  and  orders  for  the  book  than  at  any  time 
during  its  existence.  This  in  itself  would  be  a  suf- 
ficient reason  for  another  edition.  A  better  reason, 
however,  is  the  fact  that  during  the  past  few  months 
a  number  of  anaesthetic  appliances  of  superior  design 
have  been  introduced,  greatly  simplifying  the  admin- 
istration of  anaesthetics,  making  the  administration  of 
anaesthetics  less  hazardous,  and  securing  more  grati- 
fying results  for  both  patients  and  operator. 

The  manufacturers  of  nitrous  oxid  and  oxygen 
have  revolutionized  their  method  of  handling  these 
agents.  It  is  possible  now  to  obtain  cylinders  con- 
taining from  twenty-five  gallons  to  thirty-two  hun- 
dred gallons  of  nitrous  oxid  and  the  amount  of 
oxygen  corresponding.  The  larger  cylinders  are 
equipped  with  pressure  gauges,  insuring  an  even  and 
constant  flow  of  the  anaesthetic  at  all  times.  A  table 
in  conjunction  with  an  indicator  showing  the  number 
of  gallons  remaining  in  the  cylinders  relieves  the 
anaesthetist  of  the  anxiety  formerly  experienced  every 
time  an  administration  of  nitrous  oxid  and  oxygen 
was  to  be  made,  lest  the  cylinders  might  not  contain 
a  sufficient  quantity  of  material  to  complete  a  given 
case. 

1 


2  Preface  to  Second  Edition. 

The  fact  that  nitrous  oxid  can  now  be  obtained 
in  such  large  cylinders,  that  the  gas  can  be  made  to 
flow  steadily  at  a  given  pressure,  and  a  gauge  has 
been  devised  indicating  at  all  times  the  amount  of 
gas  remaining,  overcomes  in  a  measure  the  objections 
to  nitrous  oxid-oxygen  anaesthesia. 

Since  the  last  edition  of  this  book  was  issued  the 
somnoform  formula  has  been  revised,  making  it 
theoretically  safer  but  in  no  way  diminishing  its 
efficiency  as  an  anaesthetic  agent. 

A  new  somnoform  appliance  has  been  devised, 
increasing  the  possibilities  of  this  anaesthetic.  By 
means  of  this  appliance,  when  the  stage  of  analgesia 
or  anaesthesia  is  reached,  it  is  no  longer  necessary  to 
remove  the  appliance  from  the  face,  but  the  patient 
continues  to  inhale  the  anaesthetic  through  the  nose, 
thus  maintaining  the  stage  of  anaesthesia  or  analgesia 
desired.  Recent  investigations  of  Yandell  Hender- 
son and  others  showing  that  instead  of  being  a  waste 
and  deleterious  product  carbon  dioxid  is  one  of  the 
most  important  of  the  body's  hormones,  "exercising 
a  regulating  influence  on  the  action  of  the  heart,  on 
the  tonus  of  the  blood-vessels,  and  especially  on 
respiration,"  is  the  most  important  discovery  in  half 
a  century  in  the  realm  of  anaesthesia,  and  bids  fair  to 
revolutionize  anaesthetic  administration. 

In  the  light  of  these  advancements  we  feel  that 
another  edition  of  this  book  is  justified. 

Drake  University,  Des  Moines,  la. 

W.   H.    DeFORD. 

June,  1912. 


PREFACE  TO  FIRST  EDITION. 

At  the  request  of  Dr.  Burton  Lee  Thorpe,  associate 
editor  of  The  Dental  Briefs  the  writer  prepared  for  that 
journal  a  series  of  articles  entitled  "Anaesthetics  in 
Dentistry."  From  time  to  time  during  their  publica- 
tion numerous  letters  were  received  from  all  over  this 
country  and  abroad  inquiring  if  these  articles  would 
be  published  in  book  form. 

So  many  inquiries  of  this  kind  have  come  to  hand 
as  to  create  the  impression  that  a  practical  treatise  on 
anaesthetics  was  very  much  needed.  Instead  of  repro- 
ducing in  book  form  what  has  already  been  printed  in 
the  Brief,  the  author  has  used  those  articles  as  a  skele- 
ton about  which  he  has  woven  the  fabric  which  consti- 
tutes these  brief  lectures. 

The  object  of  this  book  is  to  give  the  busy  dentist 
a  working  knowledge  of  such  general  anaesthetics  as 
can  be  used  to  advantage  in  daily  practice.  With  this 
end  in  view,  the  author  has  prepared  what  he  has  to 
say  in  the  form  of  brief  lectures.  The  "how"  is  dwelt 
upon  more  than  the  "why" ;  in  other  words,  it  is  simply 
a  practical  treatise,  and  not  a  theoretical  exposition. 

The  lecture  style  enables  the  author  to  talk  directly 
to  the  individual  just  as  is  done  in  the  class-room  and 
to  repeat  and  emphasize  from  time  to  time  the  more 
important  and  essential  things,  which  is  not  permissible 
in  a  text-book. 

3 


4  Preface  to  First  Edition. 

Hewitt  has  been  quoted  frequently ;  his  text-book, 
entitled  "Anaesthetics/'  in  my  opinion,  is  the  best  that 
has  ever  been  written  on  this  subject.  Brunton,  Luke, 
Buxton,  Crile  and  others  have  been  consulted,  and, 
likewise,  papers  and  clinical  reports  published  in  The 
Medical  Association,  current  literature  in  medical  and 
British  Medical  Journal,  Journal  of  the  American 
dental  journals,  etc.,  etc. 

The  author  is  also  indebted  to  the  S.  S.  White 
Dental  Manufacturing  Company,  E.  de  Trey  &  Sons, 
the  Lennox  Chemical  Company,  A.  C.  Clark  & 
Company,  Teter  Manufacturing  Company,  and  Dr. 
Laird  W.  Nevius  for  the  cuts  of  the  various  dental 
appliances  used  in  these  pages.  W.  H.  D. 

Hotel  Victoria,  Des  Moines,  Iowa,  April,  1908. 


CONTENTS. 

LECTURE  I. 

Has  the  Dental  SuRtJEox   the   Hight  to  Administer 
CiENEitAL  Anaesthetics  ? 

Page 

I'utoiitiality  of  the  doiital  iliploiiia. — Kmployiiient  of  drugs 
otlier  than  aiui'sthetics. — The  oldest  dental  college  in  the 
world. — Dr.  Chapin  A.  Harris  endeavors  to  establish  chairs 
of  operative  and  mechanical  dentistry  in  the  Maryland 
University  Medical  College. — Dentists  may  become  mem- 
bers of  the  American  Medical  Association. — The  dentist 
should  surround  himself  with  every  possible  safeguard. — 
Dentist  would  not  be  liable  for  a  death  which  might  re- 
sult.— Dentist  is  not  held  to  insure  the  result  of  his  work.     13 

LECTURE  IL 

The  Value  of  General  An.^isthetics  to  the  Dental 
Surgeon. 

Ana'sthetics  are  employed  to  prevent  pain  and  to  avoid 
shock. — Dangerous  to  submit  patients  to  intense  pain  be- 
yond certain  limits. — Employ  anaesthetics  to  facilitate 
operating. — Saves  the  patient  suffering  and  nerve  strain. 
— A  visit  to  Dr.  Austin  C.  Hewett 's  office. — Conditions  in 
which  general  antesthetics  can  be  used  to  advantage....     21 

LECTURE  IlL 

To  Whom  Is  It  Safe  to  Administer  an  Anesthetic? 

Invalids  and  patients  in  poor  health  usually  good  subjects.— 
Opinions  of  Ochsner,  Luke,  Richardson  and  Brunton. — 
Ether  and  chloroform  contraindications. — The  strong, 
healthy  and  vigorous  more  liable  to  accidents  than  the 
weak  and  frail. — Inexperience,  ignorance  and  carelessness 
responsible  for  deaths. — Importance  of  watching  respira- 
tion       31 

LECTURE  IV. 

Elements  of  Danger. 

In  civic  matters,  ignorance  of  the  law  excuses  no  man. — 
Deaths  result  from  ignorance  of  ana?sthetic  sj-mptoms 
and  stages. — Medical  and  Dental  Colleges  are  at  fault. — 
Case  illustrating  ignorance. — Anaesthetics  in  themselves 
not  so  dangerous  as  ignorant  anaesthetists. — Carelessness 

5 


-h 


6  Contents, 

Page 
of     hospital     authorities. — Alice     Magaw. — Buxton     and 
Galloway  arraign  Medical  Colleges. — Length  of  duration 
of  angesthesia  an  element  of  danger 40 

LECTURE  V. 

Shock. 

Shock  defined. — Causes  are  psychical  and  physical. — Psychical 
causes  defined. — A  death  from  shock. — Deaths  resulting 
from  fear. — Chloroform  experiments  on  plants  and  ani- 
mals.— Shock  resulting  from  external  pressure. — Anaesthe- 
sia induction  before  the  introduction  of  general  anaes- 
thetics.— Many  who  are  hung  and  drowned  die  from 
shock. — External  pressure  exerted  by  clothing. — Spasms 
of  the  glottis.— Death  resulting  from  blood  collecting  in 
the  throat. — Nausea  during  nitrous  oxid  administration. 
— Shock  and  death  resulting  from  operating  during  par- 
tial anaesthesia. — Chloroform  idiosyncrasy 50 

LECTUEE  VL 

Dental  Fatigue. 

Dental  fatigue  and  shock  differ  only  in  degree. — Dread  of 
dental  operations. — Illustrative  cases. — Handling  of  such 
patients. — Nitrous  oxid,  somnoform,  ethyl  chloride,  or 
chloroform  recommended. — Christian  Science. — Case  of  a 
Christian  Science  healer. — Hypnotism. — Hypnotism  illus- 
trated.— Cases  illustrating  dental  fatigue  and  their  treat- 
ment        67 

LECTURE  VII. 

Elements  of  Success. 

The  operating-room. — The  rest-room. — Preparation  of  the 
patient  by  the  assistant. — Remove  corset  in  all  cases. — 
Attention  to  bladder. — Allay  fear. — Suggestion. — Illustra- 
tive case. — Assistant's  duties. — Never  anaesthetize  a 
woman  without  witnesses. — Illustrative  case. — Importance 
of  quiet  in  operating  room. — Suggestion  after  operating. 
— Prevent  blood  from  being  swallowed. — Objections  to 
hurrying  resuscitation. — Dental  chair  responsible  for 
many  failures. — The  best  anaesthetic  chair 79 

LECTURE  VIIL 

Relative  Safety  of  General  An^sisthetics. 

Nitrous  oxid  and  oxygen  the  safest  of  all  anajsthetics. — Chlo- 
roform the  most  dangerous. — Statistics  prepared  by  Jul- 
llard,  Ormsby,  St.  Bartholemew 's  Hospital,  Luke. — Unre- 
liability of  statistics. — Teter's  prolonged  case  of  anajs- 
thesia. — Nitrous  oxid  and  oxygen  handicapped. — Som- 
noform.— Ethyl  chloride  popular. — Carelessness  of  chloro- 


Contents.  7 

Page 
form  administration. — Utterly  impossible  to  obtain  cor- 
rect percentage  of  deaths  caused  by  anaesthetics. — Anajs- 
thetic  deaths  exaggerated 92 

LECTUKE  IX. 

Nitrous  Oxid  Gas. 

Part  played  by  Priestley,  Sir  Humphrey  Davy,  Wells  and  An- 
drews.— Dr.  Burton  Lee  Thorpe  settles  the  controversy. — 
Colton  's  lecture. — Wells  discovers  anaesthetic  properties 
of  nitrous  oxid. — Dr.  Riggs  extracts  tooth  for  Wells. — 
Physical  properties  of  nitrous  oxid. — Anaesthetic  action  of 
nitrous  oxid. — Claude  Martin's  experiments. — Apparatus 
for  manufacturing  nitrous  oxid. — Nitrous  oxid  cylinders. 
— Weight  of  nitrous  oxid  gas. — Nitrous  oxid  appliances. 
— Improved  cylinders,  containing  from  2.5  gallons  to  .3,200 
gallons. — A.  C.  Clark's,  and  Teter's  appliances  illustrated  104 

LECTURE  X. 

Nitrous  Oxid  Gas  Administration. 

Difficult  to  administer. — An  assistant  necessary. — Arrange- 
ment of  patient  in  the  chair. — Mouth-prop  is  important. — 
Average  time  of  induction. — Care  in  selecting  patients. — 
Adjustment  of  the  inhaler. — Amount  of  nitrous  oxid 
necessary.  —  Anajmies  susceptible.  —  Alcoholics  require 
more. — First  stage  of  anaesthesia  symptoms. — Second 
stage  of  anaesthesia  symptoms 120 

LECTURE  XL 

Nitrous  Oxid  Gas  Administration — Continued. 

Third  stage  of  anaesthesia  symptoms. — Stage  of  surgical  anaes- 
thesia. —  The  respiration.  — The  circulation.  —  Muscular 
phenomena. — Fourth  stage  of  anaesthesia  symptoms. — 
Effects  of  an  overdose. — Description  of  the  action  of 
nitrous  oxid  in  thirteen  fatalities. — Nitrous  oxid  warmed. 
— Kindly  by  patient. — Administration 131 

LECTURE  XII. 

Nitrous  Oxid  and  Oxygen. 

Oxygen  a  supporter  of  life. — Experiments  by  Priestley  and 
Demarquay. — Andrews  of  Cliicago,  the  first  to  use  this 
combination. — Safest  anaesthetic  known. — Hillischer 's  es- 
timate of  its  safety. — Apparatus. — Percentage  of  oxygen 
necessary. — Air  a  disadvantage. — Administration. — An 
unobstructed  airway  requisite. — The  four  anaesthetic 
stages, — Anaesthetic  sign. — Nitrous-oxid  and  oxygen-car- 
bon dioxid-anaesthesia. — Experiments  of  Yendall  Hender- 
son and  Mosso. — Carbon  dioxid  not  a  waste  product  but 


8  Contents, 

Page 

one  of  the  most  important  harmones. — Advantages  of  car- 
bon dioxid  as  respiratory  stimulant. — Experiments  recom- 
mended to  test  its  further  value 143 

LECTUEE  XIII. 

Nitrous  Oxid  and  Oxygen  in  Operative  Dentistry. 

Nitrous  oxid  and  oxygen  in  all  painful  operations  on  the  teeth. 
— The  Gregg  nitrous-oxid  inhaler. — De  Ford  nitrous-oxid 
and  oxygen  inhaler. — Its  use  in  sensitive  cavity  prepara- 
tion.— Eemoval  of  pulps. — Shaping  teeth  for  crowns  and 
abutments. — Opening  into  teeth  affected  with  pericement- 
itis and  acute  alveolar  abscess. — All  painful  and  fatiguing 
operations  on  the  teeth. — Administration. — Suggestions  to 
the  patient. — Description  of  a  clinical  case. — The  Teter's 
nasal  inhaler  illustrated 161 

LECTUEE  XIV. 

Ethyl  Chloride. 

First  used  by  Heyfelder. — History. — Eequisites  of  a  perfect 
anaesthetic. — Safety  of. — Action  on  the  circulation. — 
Luke's  estimate  of. — Administration. — Tubes  and  cap- 
sules.— General  and  local  ansRstheties. — Inhalers. — Action 
of  patient  under. — Neurotic  women  and  alcoholics. — 
Cyanosis. — Supervening  nausea. — Headache 161 

LECTUEE  XV. 

SOMNOFORM. 

History. — Dr.  G.  Eolland  the  discoverer. — How  an  ideal  anaes- 
thetic should  act. — Ethyl  chloride. — ^Methyl  chloride. — 
Old  and  new  formula. — Induction  period. — Available 
period  of  anaesthesia. — As  to  safety. — Stage  of  surgical 
anaesthesia  induced  by  nitrous  oxid  more  dangerous  than 
stage  of  surgical  anaesthesia  induced  by  somnoform. — 
Tubes  and  capsules. — Nausea  following  use  of  tubes. — 
Stark's  inhaler  described. — De  Ford  appliances  described.    179 

LECTUEE  XVI. 

SOMNOPORM — Continued. 

Physiological  advantages. — Circulatory  action. — Stimulating 
effect. — Earely  depresses. — Eespiration  in. — Holding  the 
breath  in. — A  twenty-five-minute  anaesthesia. — Illustra- 
tive cases. — Not  cumulative. — No  change  in  the  amount 
of  hajmoglobin  or  in  the  number  of  leukocytes.-^^Non- 
irritating  to  mucous  membriuie  and  nerves. — Syncope  of 
Duret. — No  swelling  of  tongue. — Nausea  rare. — Deeper 
anaesthesia  than  necessary. — Air  an  advantage. — Normal 
breathing. — Illustrative      case. — Nausea      cases. — Nausea 


Contents.  9 

Page 
from    swallowing     blood. —  Headache     following. — Carbon 
dioxide    195 

LECTURE    XVII. 

SoMXOFORM  Administration. 

Illustrated  by  a  ease. — Easiest  of  all  anaesthetics  to  adminis- 
ter.— Exclusion  of  air. — Method  discouraged. — Admission 
of  air. — In  multiple  extractions. — Normal  breathing. — 
Other  than  month  operations. — An  anaemic  patient. — A 
plethoric  patient. — Stark's  inhaler. — A  hysterical  patient. 
— A  nervous  girl. — Stark 's  inhaler  in  nausea  cases. — 
Stark's  inhaler  illustrated. — A  somnoform  capsule  illus- 
trated.— A   box  of  somnoform  capsules  illustrated 207 

LECTURE   XVIII. 

Somnoform    Administration — Continued. 

Oxygen  deprivation. — Excitement  under. — Never  restrain  pa- 
tient.— A  case  in  practice. — Excitement  usually  after  in- 
duction.— Illustrative  cases. — In  an  asthmatic. — A  very 
nervous  patient. — An  over-ana?sthetized  patient. — Anal- 
gesia following. — Illustrative  case. — A  dead  pulp. — 
Effects  of  tobacco,  chloral,  morphine,  alcohol,  etc. — 
Patient  intoxicated. — A  pronounced  alcoholic. — Combina- 
tion of  alcohol  and  morphine. — ^Ansesthetic  symptoms. — 
Dental  uses  of. — Sensitive  cavity  preparation. — Preparing 
tooth  for  crown. — In  acute  pericementitis. — In  acute 
alveolar  abscess. — For  exposing  and  removing  dental 
pulps.- — Evacuating  pus. — Lancing  gum. — Curetting  and 
cauterizing  pus  pockets. — Opening  into  antrum. — Ampu- 
tating roots. — For  dentigerous  cysts. — Alveolar  and  max- 
illary necrosis. — Extraction  of  teeth. — Illustrative  cases.   218 

LECTURE  XIX. 

Somnoform  Analgesia. 

Class  of  cases  in  which  indicated. — All  painful  conditions. — 
Sensitive  dentine. — Septic  j)ericementitis. — Acute  pulpitis. 
Shaping  teeth  for  crowns. — Illustrative  cases. — The  De- 
Ford  Somnoform  Appliance. — How  to  use  the  appliance.   2.S2 

LECTURE  XX. 

Chloroform  Analgesia. 

Dr.  Austin  C.  Hewett,  of  Chicago,  first  advocate. — Experi- 
mented upon  himself. — Committee  appointed  to  visit  his 
office. — Report  of  committee. —  Hlustrative  cases. — Dr. 
Hewett 's  attitude  in  relation  to  chloroform. — How  ad- 
ministered.— At  variance  with  all  recognized  authorities. — 
Recommendations  oi  the  committee 24;? 


10  Contents. 

LECTUEE  XXL 

Ether  and  Chlorofosm. 

Page 
These  agents  should  not  be  used  by  the  dental  surgeon  to  in- 
duce surgical  anaesthesia. — Hospital  recommended  for  all 
ether  and  chloroform  eases. — Objections  to  their  use  in  the 
office. — Chloroform  deaths  in  the  dental  chair. — Advan- 
tages of  a  surgical  chair. — Anaesthetist  and  nurse. — Ether 
safer  than  chloroform. — Dentist  should  know  physiological 
action  of  ether  and  chloroform. — Should  know  how  to  ad- 
minister these  agents. — History  and  physical  properties 
of  ether. — Close  and  open  methods  of  administration. — 
Luke's  estimate  of  American  anaesthetists  and  anaesthesia. 
— Protection  of  eyes  and  face. — History  and  physical 
properties  of  chloroform. — Chloroform  tests. — Preparation 
of  the  patient. — Chloroform  administration. — Hewitt's 
table  showing  anaesthetic  stages 257 

LECTURE  XXII. 

Difficulties   and   Dangers    Incident   to   Administer- 
ing General  Anesthetics  in  Dental  Practice, 
and  How  to  Meet  Them. 

Allay  fear. — Remove  the  corset. — Handling  children. — Mental 
and  physical  excitement. — Case  of  a  cigarette  fiend. — Dan- 
gers that  may  arise. — Respiratory  arrest. — Mechanical 
and  paralytic. — Toxic,  mechanical,  and  reflex  causes. — 
Mechanical  causes  and  treatment 279 

LECTURE  XXIIL 

Difficulties   and  Dangers   Incident   to  Administer- 
ing General  Anesthetics  in  Dental  Practice, 
AND  How  TO  Meet  Them. — Continued. 
Presence    of    foreign    matter    in    the    throat. — Blood,   mucus, 
vomit,  roots  and  teeth  in  the  throat. — Cases  reported  of 
foreign    matter    in    the    throat. — Respiratory    arrest    the 
result   of  paralysis  of  the  respiratory  center. — Artificial 
respiration.  —  Sylvester's     method.  —  Marshall     Hall's 
method. — Drugs  not  of  much  avail. — Circulatory  failure. 
— Treatment  of  circulatory  failure. — Horizontal 'position. 
— Heart   massage. — Tongue  traction. — Wet   towels. — Am- 
monia nitrate,  amyl  nitrite,  strychnia,  adrenalin,  caffine. — 
Equipment   recommended ..,.,,.,.,.,.. 293 


-"<iw 


ILLUSTRATIONS. 

The  Gwatbmey  Anaesthetic  Appliance 160 

The  Improved  Teter  Apparatus 108 

The   Clark    Xew   Model   Oxygen   and   Nitrous   Oxid   Gas   Ap- 
paratus       109 

The   Clark   Mixing  Device 110 

Method  of  Changing  the  Mixture — Clark  Appliance 110 

The   McKesson  Apparatus 112 

An  X-Ray  View  of  McKesson  AppHance 114 

The  Ohio  Monovalve 116 

The  Ohio  No.   1  Portable  Stand 117 

The  Ohio  Warming  Device 118 

The  No.  2  ^ennox  Stand , 150 

The   Clark   Appliance   on   Lennox   Carriage,   Large   Cylinders 

and  Pressure  Gauges 151 

The  Teter  Nasal  Inhaler 161 

The  Teter  No.  2  Nitrous  Oxid  and  Oxygen  Appliance 163 

The  Gregg  Nitrous  Oxide  Inhaler 164 

The  DeF'ord  Nitrous  Oxid  and  Oxygen  Inhaler 166-166A 

A  Somnof orm  Capsule 186 

A   Box   of   Somnof  orm   Capsules 186 

The  Stark  Somnof  orm  Inhaler 188 

The  Stark  Somnof  orm  Inhaler — Detailed  Construction 189 

The  DeFord  Somnof  orm  Appliance 192-192A 


U 


THE  REASON  THE  PATIENT  SO  RARELY 
GOES  BEYOND  THE  BORDER-LINE  LIES  NOT 
SO  MUCH  IN  THE  AGENT  EMPLOYED  AS  IN 
THE  SKILL  OF  THE  EXPERIENCED  AN^S- 
THETIZER,  WHO  KNOWS  THE  PROPERTIES 
OF  THE  DRUG  HE  USES;  WHO,  AFTER  A 
THOROUGH  EXAMINATION,  HAS  TAKEN  ALL 
PRECAUTIONS;  WHO  FORESEES  ALL  POS- 
SIBLE "ACCIDENTS";  WHO  WILL  NOT  TRUST 
TO  LUCK;  AND  WHO  REMAINS  VIGILANT 
THROUGHOUT  AND  UNTIL  THE  PATIENT 
RETURNS  TO  CONSCIOUSNESS.— The  Medical 
Times,  Jan'y,  1908. 


LECTURE  T. 

Has  the  Dental  Surgeon  the  Right  to  Administer 
General  Anaesthetics? 

The  mind  of  the  dental  surgeon  is  clear  as  to  his 
right  to  put  into  practice  everything  taught  in  his  alma 
mater,  except  general  anaesthetics.  He  is  taught  opera- 
tive dentistry,  and  operates  on  the  teeth ;  he  is  taught 
prosthetic  dentistry,  and  restores  lost  organs ;  he  is 
taught  orthodontia,  and  corrects  irregularities  of  the 
teeth;  he  is  taught  materia  medica  and  therapeutics, 
and  prescribes  constitutional  remedies ;  he  is  taught 
the  theory  and  action  of  general  anaesthetics — but 
employs  them  not. 

He  hesitates  not  a  moment  to  inject  cocaine  hypo- 
dermically  into  the  gingival  tissue,  a  procedure  that  is 
fraught  with  many,  many  times  the  risk  he  would  be 
taking  in  administering  nitrous  oxid  gas  or  somnoform. 
Surely,  if  the  dental  diploma  is  worth  anything,  if  it 
means  anything,  if  there  is  any  potentiality  in  it,  it 
carries  with  it  the  right  to  do  those  things  in  the  office 
of  the  possessor  which  are  taught  in  the  curriculum  of 
his  alma  mater. 

In  all  other  departments,  dentistry  has  made  won- 
derful progress,  outstripping  almost  every  other  pro- 
fession in  the  matter  of  advancement;  yet,  in  this 
particular  branch,  anaesthetics,  which  should  have,  by 

J3 


14  General  Ancesthetics  in  Dentistry. 

right  of  discovery  and  inheritance,  excelled  all  other 
specialties  of  medicine,  the  dentist  has  been  a  laggard 
and  a  coward.  By  right  of  discovery  and  inheritance, 
because  the  greatest  benefactor  the  human  race  has 
ever  known,  Horace  Wells,  the  discoverer  of  surgical 
anaesthesia,  was  a  dentist.  Morton,  another  dentist, 
was  the  first  to  discover  the  anaesthetic  properties  of 
sulphuric  ether ;  and  it  was  Rolland,  dean  of  the  Dental 
School  of  Bordeaux,  France,  who  experimented  with 
various  anaesthetic  mixtures  and  gave  us  the  combi- 
nation which  he  designates  somnoform.  Had  the 
rank  and  file  of  the  dental  profession  followed  in  the 
footsteps  of  Wells,  Morton  and  Rolland  and  made 
practical  application  of  the  truths  these  men  gave  us, 
dentistry  would  to-day  be  far  in  advance  of  its  present 
status. 

It  is  said  of  the  Savior,  He  came  unto  His  own, 
and  His  own  received  Him  not;  nevertheless,  the  de- 
spised, the  rejected  One  became  the  Light  of  the 
World.  So  it  has  been  with  anaesthetics.  The  world 
is  indebted  to  members  of  the  dental  profession  for 
the  discovery  of  the  anaesthetic  properties  of  nitrous 
oxid  gas  and  ether;  these  anaesthetics,  rejected  by  the 
dental  surgeon,  in  the  hands  of  the  general  surgeon 
have  become  the  greatest  boon  ever  bestowed  upon 
suffering  humanity.  As  the  Jews  will  surely  return 
to  Jerusalem,  we  should  return  to  our  own,  claim  it, 
appropriate  it,  make  use  of  it,  and  reap  the  rewards. 

Surely,  if  anyone  is  entitled  to  administer  anaes- 
thetics, it  is  the  dentist ;  not  only  because  of  the  prior- 
ity of  discovery,   but  because  of  the  necessary  pain 


General  Anccsthetics  in  Dentistry.  15 

inflicted  to  do  his  work  properly.  Has  the  dental 
surgeon  the  legal  right  to  administer  anaesthetics? 
Certainly.  If  he  has  received  proper  instruction  in 
regard  to  the  chemistry,  physiological  action,  proper- 
ties, and  behavior  of  anaesthetics ;  if  he  has  attended 
lectures  on  physical  diagnosis,  and  passed  a  successful 
examination  in  materia  medica  and  therapeutics,  and 
possesses  a  diploma  from  a  reputable  dental  college, 
why  not?  The  intelligent,  progressive  dentist  in  the 
treatment  of  incipient  alveolar  abscess  prescribes 
cathartics,  diuretics,  diaphoretics,  etc.;  in  the  treat- 
ment of  pyorrhoea,  dietary  measures  and  eliminants ; 
in  facial  neuralgia,  anodynes  and  tonics ;  in  pulpitis, 
opiates  and  soporifics ;  in  dental  caries,  antacids  and 
germicides — indeed,  his  materia  medica  vocabulary  is 
as  extensive,  if  not  more  so,  than  that  of  the  ophthal- 
mologist, rhinologist  or  laryngologist ;  yet  the  dental 
practitioner  hesitates  to  avail  himself  of  the  usefulness 
of  general  anaesthetics. 

Had  Dr.  Chapin  A.  Harris  succeeded  in  making 
good  the  ambition  of  his  life,  this  lecture  would  have 
been  unnecessary.  Dr.  Harris  was  the  founder  of  the 
Baltimore  College  of  Dental  Surgery,  the  oldest  dental 
college  in  the  world.  In  1837,  Dr.  Harris  appeared 
before  the  trustees  of  the  University  of  Maryland 
Medical  College  and  proposed  that  they  should  add 
to  their  curriculum  the  chairs  of  operative  and  mechan- 
ical dentistry,  and  those  desiring  to  prepare  them- 
selves for  the  practice  of  dentistry  should  take  the 
work  of  these  two  chairs  in  addition  to  the  medical 
Studies.     His  proposition  met  with  flat  refusal.    The 


16  General  Anccsthetics  in  Dentistry. 

following  year  he  made  another  attempt,  but  the 
trustees  denied  his  request;  so,  in  1839,  he  organized 
the  Baltimore  College  of  Dental  Surgery.  Had 
Chapin  A.  Harris  been  successful  in  having  estab- 
lished dental  chairs  in  Maryland  University  Medical 
School,  every  dentist  would  have  been  a  medical  man 
and  the  D.  D.  S.  degree  unknown.  In  keeping  with 
such  terms  as  otologist,  rhinologist,  neurologist,  etc., 
we  would  have  been  designated  odontologists,  and 
would  have  practiced  under  the  M.  D.  degree,  and  the 
question  as  to  the  right  of  dental  surgeons  to  admin- 
ister anaesthetics  never  would  have  been  raised. 

The  dental  surgeon,  it  is  true,  has  never  availed 
himself  of  all  of  his  rights  and  privileges.  He  has 
not  shown  that  broad  professional  spirit  which  should 
dominate  him ;  he  has  not  clasped  hands,  as  he  should 
have  done,  and  become  one  with  his  brother,  the 
medical  man. 

The  subsequent  conduct  of  the  medical  profession 
has  been  as  magnanimous  as  it  had  been  short-sighted 
and  narrow,  and  it  appears  as  though  the  medical 
profession  has  tried  to  right  what  might  be  denomi- 
nated the  crime  of  1837-38,  when  the  medical  faculty 
of  Maryland  University  refused  to  accept  dental  stu- 
dents on  the  terms  proposed  by  Dr.  Harris. 

When  the  Ninth  International  Medical  Congress 
convened  in  Washington  in  1889,  a  Dental  Section  was 
organized,  thus  placing  the  dental  surgeon  on  an  equal 
footing  with  the  ophthalmologist,  laryngologist,  gynae- 
cologist and  other  medical  specialties.  Of  the  eighteen 
sections  constituting  that  congress,  seldom  was  a  man 


General  Anccsthetics  in  Dentistry.  17 

admitted  to  membership  without  the  degree  of  doctor 
of  medicine.  About  this  time,  the  American  Medical 
Association  added  a  Section  on  Stomatology,  the 
membership  of  which  is  composed  of  prominent  dental 
surgeons.  In  case  of  a  death  during  anaesthesia, 
would  a  coroner's  jury  or  a  court  of  justice  say  that  a 
member  of  the  International  Medical  Congress  or  a 
member  of  the  American  Medical  Association  had  not 
the  right  to  administer  an  anaesthetic?  Membership 
in  these  associations  is  open  to  you,  and  if  you  are  not 
a  member  of  the  dental  section  of  one  or  both  of  these 
organizations,  you  have  only  yourself  to  blame. 

The  right  to  administer  an  anaesthetic,  whether  by 
a  physician  or  a  dentist,  depends  fundamentally  upon 
the  possession  of  the  requisite  knowledge,  skill  and 
experience.  A  dentist  undoubtedly  has  the  right  to 
administer  anaesthetics  in  his  practice  if  he  is  compe- 
tent to  do  so.  But  a  dentist  has  not  the  right  to 
administer  anaesthetics  unless  he  is  familiar  wdth  their 
effects  and  can  show  his  proficiency  in  this  respect. 
If  a  dentist  should  have  an  accident  or  a  fatality  of 
such  a  nature  as  a  coroner's  jury  or  the  courts  of 
justice  would  take  intt)  account,  his  right  to  administer 
anaesthetics  would  be  more  strictly  called  into  ques- 
tion than  if  a  physician  should  have  a  similar  accident. 
In  the  case  of  the  physician,  the  community  generally 
take  it  for  granted  that  he  is  competent  and  experi- 
enced with  anaesthetics ;  whereas,  if  a  dentist  had  a 
mortality  in  his  office,  they  would  probably  think  that 
he  was  not  so  competent  and  experienced  in  the  use 
of  aiuesthetics.     1 1  once,  the  dentist  who  is  adminis- 


18  General  Ancesthetics  in  Dentistry, 

tering  anaesthetics,  or  who  contemplates  doing  so, 
should  surround  himself  with  every  possible  safeguard. 
If  he  is  a  recent  graduate,  or  has  only  been  in  practice 
a  few  years,  and  his  alma  mater  gave  only  a  theoretical 
course  of  instruction  in  general  anaesthetics,  and  if, 
upon  the  witness  stand,  he  would  have  to  state  that, 
pror  to  engaging  in  practice,  he  had  never  administered 
an  anaesthetic,  he  might  be  placed  in  a  very  compromis- 
ing position.  Such  a  dentist  should,  for  his  own  pro- 
tection, go  to  an  anaesthetist  of  recognized  ability  and 
take  practical  instruction  in  administering  anaesthetics. 
As  medical  and  dental  colleges  seldom  provide  such 
instruction,  there  is  no  other  alternative.  This  would 
apply  equally  to  the  middle-aged  man,  or,  in  fact,  to 
any  dental  practitioner  who  desires  to  avail  himself  of 
the  use  of  anaesthetics  in  his  practice,  if  he  has  not  had 
previous  practical  experience.  He  owes  this  much, 
not  only  to  himself,  but  to  the  community  in  which 
he  lives,  and  to  those  who  place  their  lives  in  his 
keeping. 

In  case  of  an  accident,  inquiry  will  also  be  made  as 
to  what  antidotes  and  restoratives  were  at  command 
when  needed,  what  measures  of  resuscitation  were 
used ;  so  it  behooves  a  dental  practitioner  to  keep  him- 
self well  informed  and  abreast  of  the  times  if  he 
administers  anaesthetics. 

A  dentist  has  a  right  to  administer  general  anaes- 
thetics in  his  practice,  unless  there  is  a  statute  to  the 
contrary ;  provided,  as  previously  stated,  he  can  show 
that  he  is  competent  and  possesses  the  requisite  skill, 
knowledge  and  experience.  Davy  Crogkett  used  to  say» 


General  Anaesthetics  in  Dentistry.  19 

"Be  sure  you  are  right,  then  go  ahead."  This  is  appli- 
cable to  the  present  case.  Properly  prepare  yourself 
to  give  anaesthetics ;  have  a  good  working  knowledge 
of  the  physiology  of  the  lungs,  heart  and  kidneys; 
study  the  anatomy  of  the  nerves  that  control  circula- 
tion and  respiration ;  make  yourself  at  home  with  the 
various  methods  of  artificial  respiration ;  then  go 
ahead  fearlessly,  calmly,  knowing  that  you  will  be 
ready  in  any  emergency,  and,  in  case  of  an  accident, 
you  will  be  ready  to  face  the  highest  court  of  all,  your 
own  conscience. 

The  question  often  arises :  Would  the  dentist  be 
held  liable  for  the  consequences  if  a  death  should 
occur  while  he  is  administering  an  anaesthetic,  or  as 
the  result  of  an  anaesthetic  administered  by  him?  The 
answer  turns  on  the  right  of  the  dentist  to  administer 
the  anaesthetic.  The  test,  in  each  instance,  is  whether 
or  not  the  dentist  has  used  such  care  and  skill  in  the 
administration  of  the  anaesthetic  as  would  be  exercised 
by  the  average  dentist  practicing  in  the  same  locality. 
If  the  work  that  is  undertaken  is  within  the  scope  of 
the  dentist's  practice,  and  the  substance  administered 
is  one  which  has  been  given  a  reasonable  test,  and  if 
proper  diligence  and  skill  arc  brought  to  the  treatment 
of  the  case,  the  dentist  would  not  be  held  liable  for  a 
death  which  might  result. 

Neither  a  dentist  or  a  physician  has  any  right  to 
experiment  with  new  appliances  or  anaesthetics  which 
have  not  been  properly  tested.  Nor  would  a  dentist 
have  a  right  to  use  an  anaesthetic  unless  familiar  with 
its  effects,  and  was  competent  to  administer  it.    I  am 


20  General  Anccsthetics  in  Dentistry. 

presuming  that  this  is  a  part  of  the  course  of  study 
in  every  modern  dental  college,  and  that  the  dentist 
must  show  his  proficiency  in  this  respect  before  he  is 
admitted  to  practice  in  his  State. 

It  has  been  held  that  "where  a  person,  who  had  a 
few  days  previously  received  a  severe  blow  on  the 
head,  called  upon  a  dentist  for  the  purpose  of  having 
some  teeth  extracted,  and  which  were  extracted  by 
the  dentist  after  the  administration  of  chloroform,  the 
dentist  was  not  liable  for  a  total  stroke  of  paralysis 
which  resulted  a  few  days  later,  the  court  being  of  the 
opinion  that  the  dentist  could  not  be  held  liable  for 
consequences  that  he  could  not  reasonably  foresee, 
and  which  were  not  the  ordinary  or  probable  result  of 
what  he  did."     (Bogle  vs.  Winslow,  5  Phil.  Pa.,  136.) 

It  has  also  been  held  that  a  dentist  is  not  held  to 
insure  the  result  of  his  work,  nor  is  he  responsible  for 
a  mistake  of  judgment  where  he  exercises  reasonable 
skill  and  care.  (Wilkens  vs.  Ferrell,  10  Tex.  civ.  app., 
231.) 


General  Anesthetics  i)i  Dentistry.  21 


LECTURE  II. 

The  Value  of  General  Anaesthetics  to  the  Dental 
Surgeon. 

Anaesthetics  have  dignified  medicine;  anaesthetics 
have  made  surgery.  Anaesthetics  can  do  nearly,  if  not 
quite,  as  much  for  the  dental  surgeon  if  he  would  avail 
himself  of  their  kind  offices.  The  general  surgeon 
administers  an  anaesthetic,  primarily,  to  prevent  pain 
and  avoid  shock ;  secondarily,  to  facilitate  operating. 
In  some  cases,  the  patient  could  undergo  the  operation 
without  an  anaesthetic,  just  as  the  dental  surgeon  com- 
pels his  patients  to  undergo  the  severest  of  pain  in  his 
chair.  The  general  surgeon  administers  anaesthetics 
to  prevent  shock,  for  it  is  shock,  surgical  shock,  that 
kills. 

Prior  to  the  general  use  of  anaesthetics,  deaths  were 
frequent  in  simple  arm  and  leg  amputations,  while 
now,  under  anaesthesia,  one  seldom  hears  of  death 
during  these  operations.  It  was  shock  that  killed 
them.  Thousands  of  brave  soldiers  in  the  Civil  War, 
wounded  by  the  enemy,  died  on  the  field  of  battle 
before  medical  assistance  could  reach  them,  not  from 
hemorrhage,  not  because  a  vital  part  was  entered  by 
bullet  or  shell,  but  from  shock,  the  result  of  intense 
pain.     Anaesthetics,  tiicn.  are  used  primarily  to  prevent 


22  General  Ancesthetics  in  Dentistry. 

pain  and  to  avoid  shock.  In  this  enlightened  age  no 
surgeon,  except  the  dental  surgeon,  permits  a  patient 
to  undergo,  without  an  anaesthetic,  tortures  equal  in 
severity  and  duration  one  is  subjected  to  during  the 
average  dental  operation.  Through  apprehension  that 
the  instrument  may  slip  and  enter  the  soft  tissues,  or 
fear  that  a  bur  may  accidentally  plunge  into  a  live 
pulp,  patients  are  subjected  not  only  to  physical  pain, 
but  to  mental  suffering  as  well.  Thus  the  nervous 
system  is  at  its  highest  tension,  and  the  patient  often 
leaves  the  chair  fatigued,  exhausted,  sometimes  bor- 
dering on  a  state  of  collapse,  and  at  each  subsequent 
sitting  the  strain  is  greater.  That  is  not  all.  Upon 
retiring,  the  nerves  take  up  the  impression  made  upon 
them,  and  all  night  long,  in  effect  the  dental  bur  is 
whirling  at  lightning  speed;  the  corundum-wheel  is 
grinding  sensitive  dentine;  the  sandpaper  strip  is 
drawn  rapidly  between  the  teeth,  setting  them  on  fire, 
as  it  were,  and  there  is  no  rest  even  in  the  quiet  of  the 
night. 

Exhaustion  of  the  vaso-motor  centers,  rather  than 
structural  lesions,  is  what  produces  shock,  and  I  want 
to  emphasize  the  fact  that  it  is  a  dangerous  procedure 
to  submit  even  the  physically  strong  to  intense  pain 
beyond  certain  limits.  Under  the  benign  influence  of 
anaesthesia,  physical  suffering  is  prevented,  mental 
torture  obviated,  and  the  patient  steps  from  the  chair 
without  fatigue,  and  an  otherwise  restless  night  be- 
comes one  of  sweet  repose  and  refreshment.  If  we  only 
knew,  if  there  was  any  way  to  ascertain  just  how 
much  the  dental  surgeon  contributes  to  the  sum  total 


General  Ancesthetics  in  Dentistry.  23 

of  the  neurasthenia  which  is  so  prevalent  at  the 
present  time,  it  would  be  interesting,  but  "where 
ignorance  is  bliss,  'tis  folly  to  be  wise." 

We  are  all  familiar  with  such  expressions  as,  "It 
used  to  be  that  I  did  not  mind  having  teeth  filled,  but 
the  very  thought  of  it  now  gives  me  a  nervous  chill ;  I 
have  no  nerve  any  more";  "I  had  rather  die  than  have 
this  tooth  out,  and  I  hoped  that  I  would  before  it  was 
necessary  to  have  another  extracted";  "I  have  never 
recovered  from  the  last  time  when  I  had  several  out 
without  taking  anything" ;  and  kindred  remarks.  The 
nervous  system  has  been  impaired  by  previous  opera- 
tions, and  the  old  impressions  of  sufTering  and  exhaus- 
tion are  awakened  at  the  very  thoughts  of  taking  the 
dental  chair. 

Bold  in  other  directions,  commendably  progressive 
in  all  that  relates  to  manipulative  ability  and  artistic 
development,  the  dental  surgeon  shrinks  from  anaes- 
thetics. He  cuts  into  living  tissue,  lacerating  the 
nerves  themselves,  "performing  laparotomies  upon  the 
teeth,"  so  to  speak,  and  the  anaesthetic  usually  em- 
ployed is  that  of  witty  speech,  or  an  amusing  story, 
while  the  patient  sufifers,  cringes,  agonizes  almost  to 
the  state  of  collapse. 

The  dental  surgeon  does  not  seem  to  realize  the 
extent  to  which  the  nervous  syetem  is  impaired  as  the 
result  of  operations  on  the  teeth.  After  prolonged 
operations  the  neurons  become  exhausted  and  there  is 
a  condition  which  I  denominate  dental  fatigue,  border- 
ing on  collapse  or  shock.  When  a  patient  returns  to 
the  ofifice  and  remarks  that  he  was  completely  used  up, 


24  General  Anaesthetics  in  Dentistry. 

after  the  last  sitting,  the  dentist  makes  light  of  it, 
laughs  it  ofif,  adjusts  the  rubber  dam  and  begins  the 
nerve-racking  procedure  for  another  hour  or  two. 
Fortunately,  I  have  been  almost  immune  from  dental 
caries  and  have  spent  but  few  hours  in  the  dental  chair 
in  a  lifetime,  and  my  case  is  hardly  a  fair  example 
of  that  dental  fatigue  which  results  from  painful  opera- 
tions, or  operations  of  long  duration,  even  though  not 
very  painful.  However,  I  had  one  experience  when 
a  dental  student  in  college  that  I  have  never  forgotten. 
The  professor  of  operative  dentistry  built  up  with  gold 
an  impaired  lower  molar.  The  sitting  was  from  ten 
o'clock  until  one.  I  had  expected  to  operate  that 
afternoon  at  the  clinic,  but  so  exhausted,  so  fatigued 
was  I  at  the  conclusion  of  the  operation  that  I  went 
to  my  room  and  remained  there  in  bed  from  one  o'clock 
Saturday  until  Monday  morning.  Ten  years  elapsed 
before  it  was  necessary  to  again  become  a  patient. 
This  time  caries  had  so  nearly  approached  the  pulp  in 
an  upper  bicuspid  that  it  was  necessary  to  expose  and 
devitalize  the  formative  organ  of  the  tooth.  Thou- 
sands of  times  had  I  sent  patients  to  their  homes  with 
an  arsenical  application  on  or  in  close  proximity  to 
the  pulp,  but  not  until  I  experienced  the  effects  of 
that  little  1-100  of  a  grain  of  arsenious  acid,  smothered 
in  sulphate  of  morphia  and  cocaine,  did  I  realize  the 
weight  of  woe  that  I  had  unsuspectingly  contributed 
to  suffering  humanity.  That  dose  laid  me  up  for  a 
day  and  a  half.  When  I  contemplate  those  more 
unfortunate  patients  where  the  operations  on  their 
teeth  require  two  or  three  sittings  a  week  for  a  period 


General  Ancvsthetics  In  Dentistry.  25 

of  several  weeks,  and  others  who  find  it  necessary  to 
visit  a  dental  surgeon  every  six  months  for  profes- 
sional services,  I  am  satisfied  that  more  humanitarian 
methods  should  be  adopted.  The  dentist  should  take 
into  consideration  the  physical  well-being  of  his  pa- 
tients and  adopt  those  methods  which  are  the  least 
destructive  of  nerve  force  and  vitality. 

The  general  surgeon  employs  anaesthetics,  sec- 
ondarily, to  facilitate  operating.  Imagine,  if  you  can, 
that,  on  awakening  on  the  morrow,  the  knowledge  of 
all  anaesthetics  was  lost  to  man,  and  that  their  formulae 
or  component  parts  were  blotted  out  from  memory. 
Picture  surgeons,  Samson-like,  shorn  of  their  strength, 
as  they  watch  patients  and  nurses  assemble  at  the 
various  hospitals.  Where  is  the  surgeon  who  could 
operate  successfully  under  these  conditions?  Without 
anaesthetics,  the  occupation  of  the  surgeon  would  be 
gone  and  the  hospitals  would  have  to  be  converted 
into  sanitariums  and  asylums,  where  sufifering  human- 
ity must  wear  itself  out  in  pain  and  misery. 

General  anaesthetics  in  dentistry  can  be  made  to 
play  a  double  part — save  the  patient  from  sufifering 
and  nerve  strain,  and  relieve  the  operator  of  the  debili- 
tating influences  incident  to  controlling  patients, 
highly  nervous  and  hysterical,  who  sap  his  energy, 
absorb  his  vitality,  and  deplete  his  mentality. 

Some  twenty  years  ago,  in  Chicago,  while  visiting 
the  office  of  a  dentist,  who  has  ever  since  been  a 
warm  personal  friend,  I  beheld  that  which  im- 
pressed me  deeply.  Although  for  ten  years  previously 
I    had   been    interested   in   anaesthetics  and   gave   the 


26  General  Anccsthetics  in  Dentistry. 

subject  as  much  time  and  attention  as  a  busy  prac- 
titioner could  well  bestow  upon  it,  it  was  not  until  the 
summer  of  1893  that  I  fully  awakened  to  the  possibili- 
ties of  general  anaesthetics  in  dentistry. 

In  this  office  were  two  chairs,  each  presided  over 
by  a  lady  assistant.  Upon  completing  an  operation 
the  chair  was  vacated  and  another  patient  called,  the 
operator  passing  quietly  from  one  chair  to  another. 
This  dental  surgeon  refused  to  operate  for  anyone  who 
would  not  inhale  a  general  anaesthetic,  and  he  informed 
me  that  he  averaged  twent_v  administrations  a  day. 
He  maintained  that  under  chloroform  analgesia  the 
patient  was  saved  the  suffering  and  shock  incident  to 
such  operations  without  anaesthetics ;  that  he  was 
enabled  to  make  a  more  thorough  cavity  preparation, 
and  he  could  accomplish  in  a  few  minutes,  under  anaes- 
thesia, or  analgesia,  results  which  would  require  a 
long  sitting  without  the  aid  of  an  anaesthetic. 
Although  he  was  a  man  well  advanced  in  years,  three 
score  years  and  ten,  he  said  that  he  was  enabled  to 
accomplish  this  amount  of  work  only  because  it  did 
not  tire  him  to  operate  when  he  could  proceed  with 
as  much  assurance  as  though  he  was  operating  on  an 
inanimate  substance. 

I  recall  an  operation  that  greatly  interested  me. 
A  young  lady  presented  with  pyorrhoea.  One  central 
incisor  had  elongated  fully  a  quarter  of  an  inch; 
indeed,  when  the  lips  were  closed  naturally,  the  tooth 
projected  so  as  to  be  seen.  He  said  to  me:  "What 
would  you  do  in  this  case?"  I  replied  in  jest:  "Take 
a  hammer  and  drive  it  back  on  a  line  with  the  other 


General  Anesthetics  in  Dentistry.  27 

teeth."  He  replied:  "That  is  just  exactly  what  I 
will  do."  He  administered  chloroform,  extracted  the 
tooth,  enlarged  the  alveolar  socket,  removed  the  pulp 
from  the  tooth,  filled  the  root  canal,  placed  the  tooth 
in  its  socket,  drove  it  to  place  with  a  hammer,  made 
a  splint  and  adjusted  it,  and  the  time  consumed,  from 
the  first  inhalation  of  chloroform  until  the  patient  left 
the  chair,  was  just  eleven  minutes.  Without  his 
knowledge,  I  had  timed  this  operation,  and  he  oper- 
ated and  talked  and  explained  as  one  does  at  a  clinic, 
showing  no  haste. 

In  those  cases  where  caries  approached  the  pulp 
to  such  close  proximity  as  to  render  inflammation  and 
death  of  the  pulp  liable  as  the  result  of  a  filling,  it  was 
the  custom  of  this  dentist  to  administer  chloroform, 
open  into  the  pulp  chamber  and  amputate  the  bulbous 
or  crown  portion  of  the  pulp  with  a  large  bur.  Upon 
the  cessation  of  hemorrhage  he  burnished  gold  foil 
over  the  stump,  leaving  the  root  portion  alive,  filled 
with  cement,  and  in  the  course  of  two  or  three  months 
completed  the  operation. 

I  saw  him  operate  on  several  of  these  cases  and  the 
patients  assured  me  that  they  experienced  no  pain.  I 
also  saw  cases  which  had  been  operated  on  for  pulp 
amputation  months  previously  and  the  teeth  showed 
no  signs  of  discoloration,  and  they  responded  to  heat 
and  cold,  showing  that  the  pulps  were  alive,  main- 
taining the  natural  color  of  the  teeth  and  preventing 
the  formation  of  alveolar  abscess. 

Attention  had  been  called  to  the  fact  that  Dr.  A.  C. 
Hewett,  of  Chicago,  for  it  was  he  to  whom  1  refer,  was 


28  General  Ancrsthetics  in  Dentistry. 

operating  on  teeth  under  chloroform  analgesia,  and  he 
had  delivered  addresses  on  two  occasions  before  the 
Iowa  State  Dental  Society.  So  impressed  was  this 
society  with  the  claims  made  by  this  speaker  that  a 
committee  was  appointed  to  go  to  Chicago  and  investi- 
gate his  work.  I  was  fortunate  in  being  made  a 
member  of  that  committee  and  wrote  the  report,  which 
was  published  in  full  in  the  proceedings  of  the  Society 
for  the  year  1892. 

During  the  three  days  spent  with  Dr.  Hewett  on 
that  occasion,  the  committee  witnessed  almost  every 
operation  common  to  dentistry,  and  not  in  a  single 
case  operated  on  was  there  an  alarming  symptom,  nor 
was  there  nausea  or  delay  of  any  kind  incident  to  the 
anaesthetic. 

Here  was  food  for  thought ;  here  was  something 
worthy  of  taking  home ;  here  was  something  worth 
putting  to  the  test.  Beginning  at  first  with  favorable 
cases,  I  found  in  a  few  weeks  that  chloroform  worked 
as  happily  for  me  as  for  Dr.  Hewett. 

This  was  a  glimpse  of  the  promised  land,  a  boon 
alike  to  both  dentist  and  patient.  Each  year  the  con- 
viction that  the  dentist  should  become  proficient  in 
administering  anaesthetics  and  should  employ  them  in 
his  daily  practice,  has  steadily  grown. 

General  anaesthetics  in  dentistry  are  valuable  to  the 
dental  surgeon  and  may  be  used  for  the  following 
purposes : 

First:  To  prevent  pain,  thus  eliminating  fatigue, 
collapse  and  shock. 


General  Ancssthetics  in  Dentistry.  29 

Second :  Short  sittings  are  made  possible,  which  is 
beneficial  to  both  dentist  and  patient. 

Third:  Enables  the  operator  to  do  more  thor- 
oughly the  operation  to  be  performed. 

Fourth:  Enables  the  operator  to  accomplish  an 
increased  amount  of  work  in  a  day. 

Fifth  :  Dignifies  dentistry,  elevating  it  to  the  plane 
of  surgery,  and  augments  the  receipts  of  practice. 

It  is  true  that  much  of  the  supposed  hurt  is  imagi- 
nary, purely  mental,  but  that  fact  does  not  make  it 
an}^  easier  for  patients.  It  is  real  to  them,  and  even 
the  anticipation  of  being  hurt  disturbs  the  equilibrium 
of  the  nervous  system.  In  many  cases  the  vibrations 
resulting  from  the  contact  of  bur  with  dentine  or 
enamel,  even  where  there  is  no  pain,  are  sufficient  to 
unnerve  the  patient  during  the  entire  operation.  It 
is  worth  while  to  employ  anaesthetics  in  these,  if  in  no 
other  cases,  for  these  patients  consume  the  greater 
portion  of  the  operator's  time  as  well  as  his  strength. 
How  often  do  you  feel  completely  exhausted  after 
performing  some  simple  operation  for  a  nervous, 
hysterical  patient,  and  almost  wish  that  he  would 
never  present  himself  again  for  an  operation?  An:es- 
thetize  such  patients,  give  them  the  bliss  of  anaesthetic 
relaxation,  if  not  of  unconsciousness,  and  they  will 
prove  to  be  quite  model  patients. 

General  anaesthetics  can  be  employed  to  advantage 
in  the  following  cases : 

1,  Adjusting  the  rubber  dara  where  cavities  of 
decay  are  to  be  excavated  along  the  gingival  margin 


30  General  Anccsthetics  in  Dentistry. 

and  a  cervical  clamp  employed  to  hold  the  dam   in 
position. 

2.  Cavity  preparation  for  fillings  and  inlays. 

3.  Removing  fillings  in  cases  of  pulpitis. 

4.  Exposing  live  pulps  and  immediate  removal  of 
same. 

5.  Opening  into  teeth  in  cases  of  acute  perice- 
mentitis or  acute  alveolar  abscess. 

6.  Instrumentation  and  application  of  caustics  in 
pyorrhoea. 

7.  Lancing  abscesses. 

8.  Extracting  teeth. 

9.  Other  painful  operations,  and  operations  the 
nature  of  which  produce  dental  fatigue. 

10.  Oral  surgical  operations,  such  as  cleft-palate, 
hare  lip,  empyemia  of  antrum,  impacted  third  molars, 
dentigerous  cysts,  adenoid  vegetations,  alveolar  and 
maxillary  necrosis  and  various  tumor  formations  in 
and  about  the  mouth. 


General  Anesthetics  in  Dentistry.  31 


LECTURE  III. 
To  Whom  it  is  Safe  to  Administer  an  Anaesthetic. 

Having  shown  that  the  properly  qualified  dental 
practitioner  has  the  right  to  administer  general  anaes- 
thetics in  his  daily  work  and  pointed  out  the  possibili- 
ties and  advantages  of  operating  on  patients  during 
anjesthesia  or  analgesia,  the  question  naturally  arises, 
to  whom  is  it  safe  to  administer  an  anaesthetic? 
There  is  a  mistaken  idea  on  the  part  of  both  the  pro- 
fession and  the  laity  as  to  whom  it  is  safe  to  adminis- 
ter anaesthetics.  A  widespread  impression  prevails 
that  if  the  heart  is  sound  there  can  be  no  risk, 
"whereas  in  about  ninety  per  cent,  of  the  fatalities 
from  chloroform,  at  the  post-mortem  examinations, 
the  heart  is  found  to  be  perfectly  normal."     (Luke.) 

Dr.  Ochsner,  in  the  last  edition  of  his  "Clinical 
Surgery,"  says:  "In  my  experience,  patients  suffering 
from  organic  heart  lesions  have  never  had  any  serious 
or  alarming  difficulty  during  the  administration  of 
anaesthetics,  which  is  not  true  of  patients  whose  hearts, 
lungs  and  kidneys  were  evidently  normal." 

"It  is  a  remarkable  fact  that  an  individual  whose 
health  has  become  impaired  by  disease  is  often  a  better 
subject  for  an  anaesthetic  than  one  who  enjoys  robust 
health.     Although    his    heart    and    lungs    may    be    in 


32  ^     General  Ancesthetics  in  Dentistry. 

excellent  condition  and  able  to  stand  almost  any  strain, 
yet  he  will  not  pass  so  easily  into  anaesthetic  sleep  as  a 
less  robust  patient,  owing  to  the  more  frequent  occur- 
rence of  struggling  excitement  which  will  interfere 
with  the  respiratory  rhythm."     (Luke.) 

Richardson  thinks  "the  bad  effects  of  anaesthesia 
are  largely  due  to  over-confidence  and  non-experience 
of  administration."  He  has  never  seen  a  death  from 
ether  itself,  and  he  thinks  that  while  there  may  have 
been  some,  the  number  is  extremely  small.  Only  uri- 
nary suppression  and  pneumonia  seem  to  him  impor- 
tant. Where  a  patient  dies  after  a  severe  operation, 
even  with  these  symptoms,  it  is  an  unwarrantable 
assumption  that  death  was  due  to  the  anaesthetic  and 
not  the  operation. 

Accidents  from  the  subcutaneous  or  hypodermic 
use  of  cocaine  would  be  much  more  perilous  than  ether 
accidents ;  the  former  would  be  caused  by  the  intrinsic 
danger  of  the  drug,  the  latter  from  disregard  of  danger 
signals,  or  over-etherization. 

Heart  disease  is  usually  regarded  as  a  contra-indi- 
cation  to  general  anaesthesia,  but  that  is  not  according 
to  his  experience.  His  chief  anxiety  has  been  from 
diseases  of  the  lungs;  but  he  is  inclined  to  think  that 
his  anxiety  is  seldom  justified  by  facts.  Failure  to 
breathe  is  a  serious  matter,  and  it  is  fortunate — and  in 
this  fact  lies  the  great  safety  of  ether — that  a  patient 
with  healthy  lungs,  at  least,  always  reacts  to  artificial 
respiration. 

As  a  rule,  simple  weakness  does  not  contra-indicate 
anaesthesia.     Of    the    two    classes    of    patients — the 


General  Ancusthetics  in  Dentistry.  33 

istrong,  robust,  full-blooded  with  bounding  pulse,  and 
the  frail,  delicate,  weak,  even  those  that  might  be 
denominated  invalids,  I  much  prefer  the  latter  for 
anaesthesia.  About  half  of  those  who  come  to  me  to 
be  anaesthetized  complain  of  heart  trouble,  and  these 
are  the  patients  that  cause  me  the  least  anxiety. 
Many  volunteer  the  statement  that  their  physician  has 
warned  them  never  to  take  an  anaesthetic — these  prove 
good  subjects,  also.  But  those  patients  who  take  the 
chair  saying,  "My  heart  is  sound,  my  lungs  are  all 
right,  you  better  get  some  one  to  help  hold  me  or  I 
may  make  you  trouble" — patients  with  strong  phy- 
siques and  active  brains — these  are  the  cases  that 
require  the  greatest  care  and  skill  in  administering 
anaesthetics. 

An  experience  of  thirty  years  with  the  more  com- 
monly used  general  anaesthetics  has  convinced  me 
that  the  heart  is  rarely,  if  ever,  primarily  affected. 

I  have  seldom  administered  ether  or  chloroform  for 
a  major  surgical  operation,  that,  at  some  stage  of  the 
anaesthesia,  the  patient  did  not  momentarily  cease 
breathing  (nothing  serious),  but  never  have  I  known 
the  heart  to  cease  beating  or  witnessed  a  fatality. 

I  am  strongly  of  the  opinion  that  general  anaes- 
thetics cause  the  respiration  to  fail  before  the  heart 
becomes  affected,  and  we  all  recognize  the  fact  that 
it  is  much  easier  to  re-establish  breathing  than  to 
re-establish  the  circulation.  There  is  no  higher  au- 
thority on  this  subject  than  T.  Lauder  Brunton,  who 
was  chairman  of  the  Hyderabad  Commission,  who 
says:     "So    far    as    the    anaesthetic    is    concerned,    in 


34  General  Anccsthetics  in  Dentistry. 

99,999  out  of  100,000  cases  it  causes  the  respiration  to 
fail  before  it  affects  the  heart,  and  if  you  attend  to  the 
respiration  carefully  I  do  not  believe  you  run  very 
much  risk  of  the  heart.  But  remember  that  I  make 
this  statement  only  in  regard  to  the  anaesthetic,  for 
shock  may  have  a  different  effect." 

We  have  been  taught  or  impressed  by  the  litera- 
ture extant  on  anaesthetics  that  it  is  safe  to  administer 
ether  if  the  lungs  are  sound,  and  safe  and  proper  to 
administer  chloroform  when  the  heart  is  normal.  If 
this  were  true,  it  would  simplify  the  matter  of  select- 
ing the  proper  anaesthetic  each  time  for  a  given  case, 
but  the  human  race  is  not  divided  into  two  classes, 
one  with  sound  hearts  and  the  other  with  sound  lungs. 
Luke  claims  that  in  ninety  per  cent,  of  the  deaths 
occurring  during  chloroform  anaesthesia  the  heart  was 
perfectly  normal.  As  to  the  number  of  fatalities  of 
those  possessing  sound  lungs  under  ether  anaesthesia, 
I  have  no  statistics  at  hand,  but  I  doubt  not  the  per- 
centage would  be  as  high,  for  I  am  satisfied  that  in 
neither  case  is  the  ether  or  chloroform  per  se  respon- 
sible for  these  deaths. 

It  is  impressive  to  state  that  in  the  case  of  sound 
lungs  administer  ether,  and  in  the  case  of  normal 
heart  administer  chloroform ;  but  you  will  frequently 
find  in  the  same  patient  an  impaired  heart,  a  tubercular 
lung,  a  diseased  kidney,  a  shattered  nervous  system, 
yet  an  anaesthetic  must  be  administered  because  of 
some  gynaecological  complication  or  an  inflamed  ap- 
pendix. A  well-known  writer  on  anaesthesia  says : 
"You  must  not  administer  ether  in  bronchitis  or  inflam- 


General  Anccsthetics  in  Dentistry.  35 

matory  conditions  of  the  pulmonary  tract,  in  acute  or 
chronic  nephritis,  aneurism,  atheroma,  endocarditis, 
and  high-tension  pulse,  in  operations  on  the  brain,  in 
operations  on  the  pelvic  cavity,  because  it  does  not  as 
thoroughly  relax  as  chloroform,  or  to  those  addicted 
to  alcohol  or  narcotics." 

"Chloroform  is  contra-indicated  in  empyemia  with 
dilatation  of  the  right  side  of  the  heart,  fatty  degen- 
eration of  the  heart  muscles,  dilatation  of  the  heart 
with  corresponding  hypertrophy,  in  extreme  prostra- 
tion, in  anaemia  or  shock,  collapse,  hemorrhage,  very 
stout  subjects,"  etc.,  etc. 

Indeed,  it  would  require  a  page  to  enumerate  the 
conditions  contra-indicating  anaesthetics ;  yet  thou- 
sands of  operations  are  performed  daily  for  patients 
having  one  or  more  of  these  conditions  and  a  mor- 
tality rarely  occurs.  In  some  hospitals  ether  is  used 
almost  exclusively,  in  others  chloroform.  The  mat- 
ter of  preference  is  confined  not  only  to  hospitals,  but 
to  sections  of  the  country  where  one  anaesthetic  or  the 
other  will  be  used  almost  invariably  independent  of 
the  physical  condition  of  the  patient.  One  would 
naturally  suppose  that  a  patient  having  several  of  the 
conditions  named  could  not  safely  take  a  general 
anaesthetic ;  but  no  surgeon  refuses  to  operate  for 
these  cases,  yet  deaths  are  so  rare  under  anaesthetics 
that  many  prominent  surgeons  have  never  witnessed 
a  mortality. 

To  whom  it  is  safe  to  administer  an  anaesthetic 
becomes  a  perplexing  problem  when  the  strong,  the 
healthy,  the  robust  are  more  liable  to  accidents  than 


36  General  Anaesthetics  in  Dentistry. 

the  weak,  the  frail  and  the  patient  in  poor  health ; 
when  eminent  surgeons  find  that  patients  with  im- 
paired hearts,  kidneys  and  lungs  are  safe,  while  those 
whose  vital  organs  are  in  a  state  of  health  are  liable 
to  accidents.  Further,  notwithstanding  a  long  list  of 
pathological  conditions,  any  one  of  which,  we  are  told 
by  some  authorities,  contra-indicates  a  certain  anaes- 
thetic, in  the  hands  of  other  anaesthetists  patients 
having  these  conditions  are  ansesthetized  every  day 
without  accidents  or  subsequent  trouble.  How  is  one 
to  intelligently  determine  to  whom  it  is  safe  to  admin- 
ister an  ansesthetic?  In  hospitals,  and  usually  in  pri- 
vate practice,  a  careful  preliminary  examination  is 
made  to  determine  the  condition  of  the  heart,  lungs, 
and  kidneys  of  the  patient  to  be  ansesthetized.  This 
report  is  recorded  on  blanks  made  for  the  purpose  and 
placed  in  the  hands  of  the  anaesthetist.  He  makes  a 
study  of  this  report  and  decides  in  advance  the  anses- 
thetic to  be  employed.  If  there  are  heart  lesions,  he 
knows  it.  If  there  are  abnormal  pulmonary  condi- 
tions, he  is  aware  of  that.  If  albuminuria  is  present, 
the  examination  has  shown  it.  The  anaesthetist  is 
ready  for  the  battle,  knowing,  as  it  were,  in  advance, 
the  weak  places  in  the  ranks  of  the  enemy. 

It  is  said,  to  be  forewarned  is  to  be  forearmed.  In 
cases  of  pathological  lesions,  the  anaesthetist,  knowing 
in  advance  what  may  happen,  is  careful  to  the  minutest 
detail  in  the  choice  and  the  method  employed  in  ad- 
ministering the  anaesthetic.  Never  for  a  moment  does 
he  take  his  attention  from  the  patient,  watching  for 
the  least  deviation  from  normal  of  the/espiration,  cir- 


General  Ancesthetics  in  Dentistry.  37 

culation,  and  the  pupil.  This,  to  my  mind,  is  the 
explanation  when  Dr.  Ochsner  says:  "In  my  experi- 
ence, patients  suffering  from  organic  heart  lesions 
have  never  had  any  serious  or  alarming  difficulties 
during  the  administration  of  anaesthetics,  while  this  is 
not  true  of  patients  whose  hearts,  lungs,  and  kidneys 
arc  evidently  normal."  The  vital  organs  being  pro- 
nounced normal,  the  anaesthetist  is  not  so  careful  as 
to  what  anaesthetic  he  will  employ.  He  begins  with 
a  stronger  vapor,  perhaps,  than  he  should,  and  pushes 
it  along  faster  than  in  a  less  robust  subject,  and  prob- 
ably becomes  interested  in  the  operation  himself,  there 
apparently  being  no  risk  in  regard  to  the  anaesthetic, 
allows  the  patient  to  go  down  deeper  than  necessary, 
or  to  come  out  from  under  the  influence  of  the  anaes- 
thetic, not  exercising  that  extreme  care  and  watchful- 
ness he  would  if  he  knew  his  patient  had  a  heart 
lesion.  I  am  satisfied  that  it  is  not  the  anaesthetic  that 
is  primarily  responsible  for  accidents  during  anaes- 
thesia when  the  accident  is  traced  to  the  anaesthetic, 
but  it  is  the  fault  of  the  anaesthetist,  who  has  not  prop- 
erly administered  the  anaesthetic. 

Inexperience,  ignorance,  and  carelessness  on  the 
part  of  the  anaesthetist  are  responsible  for  more  deaths 
than  the  action  of  all  anaesthetics  combined. 

If  it  is  true,  as  Luke  says,  that,  '''in  about  ninety 
per  cent,  of  the  fatalities  that  occur  during  chloroform 
anaesthesia,  the  post-mortem  shows  the  heart  to  be 
perfectly  normal,"  if  chloroform  was  the  cause  of  the 
death,  the  theory  to  administer  chloroform  w'hen  the 
heart  is  sound  is  erroneous. 


38  General  Ancesthetics  in  Dentistry. 

Again,  if  the  heart  is  found  normal  in  ninety  per 
cent,  of  chloroform  fatalities,  it  looks  as  if  the  fatal 
action  must  have  manifested  itself  through  some 
other  organ  than  the  heart.  It  would  hardly  be  the 
kidneys,  and,  eliminating  the  kidneys,  death  must  be 
caused  by  paralysis  of  the  respiration. 

For  3ears  I  have  maintained  that  respiration  was 
the  important  thing  to  watch,  long  before  I  knew  that 
Brunton  claimed  that,  in  so  far  as  the  anaesthetic  itself 
was  concerned,  in  "99,999  out  of  100,000  cases  the 
respiration  ceased  before  the  heart's  action."  It  is 
preposterous  to  hold  anaesthetics  so  largely  responsible 
for  deaths  that  occur  during  anaesthesia,  and  I  shall 
show  in  another  lecture  that  only  occasionally  are 
deaths  caused  from  anaesthetics,  and  these  usually  be- 
cause the  anaesthetic  was  not  properly  administered. 
I  am  aware  of  the  fact  that  chloroform  is  a  proto- 
plasmic poison  and  ether  a  nephretic  irritant;  but  the 
question  is  not  what  ether  and  chloroform  can  do  ad 
libitum,  but  what  effect  they  have  upon  the  tissues  and 
organs  of  the  body  when  used  as  anaesthetics,  intelli- 
gently and  properly  administered. 

This  chapter  is  written  from  a  clinical  standpoint, 
and,  clinically,  the  most  important  thing  is  to  watch 
the  breathing.  Not  for  a  moment  should  the  atten- 
tion of  the  anaesthetist  be  diverted  from  the  respira- 
tion. In  the  matter  of  observing  respiration  not  only 
the  eye  but  the  ear  can  be  trained  to  assist.  Do  not 
wait  for  something  startling  to  occur,  but  the  moment 
there  is  the  least  deviation  from  the  normal  institute 
measures  to  compel  the  patient  to  breathe  properly. 


General  Aiucstlietics  in  Dentistry.  39 

"If  you  attend  to  the  respiration  carefully,  I  do  not 
believe  that  you  run  very  much  risk  of  the  heart.  This 
statement  refers  strictly  to  the  anaesthetic,  for  shock 
may  have  a  different  effect."     (Brunton.) 

From  my  standpoint,  then,  the  question  to  whom 
is  it  safe  to  administer  an  anaesthetic  for  dental  opera- 
tions turns  on  the  matter  of  properly  administering  the 
anaesthetic.  It  becomes  a  personal  equation.  The 
an?Esthetist  must  be  one  who  possesses  the  ability  to 
inspire  the  patient  with  confidence,  to  allay  all  fear  as 
to  the  probable  outcome,  and  relieve  the  mind  of  all 
anxiety. 

The  psychical  element  is  one  of  the  most  potent 
with  which  we  have  to  deal.  Timidity  and  nervous- 
ness on  the  part  of  the  one  who  is  to  administer  the 
anaesthetic  is  communicated  to  the  patient,  and  un- 
nerves him  for  the  ordeal.  You  can  not  administer 
anaesthetics  successfully  unless  you  have  confidence  in 
both  yourself  and  the  anaesthetic  and  understand  how 
to  administer  them. 

I  had  rather  take  my  chances  on  anaesthetizing  a 
patient  with  valvular  lesion  of  the  heart,  a  morbid 
kidney,  and  an  impaired  lung,  mind  tranquil,  than  to 
anaesthetize  a  patient  who  takes  the  chair  white  with 
fear,  gasping  with  short,  quick  breaths,  circulation 
"off,"  with  normal  heart,  lungs  and  kidneys.  As  I 
look  back  over  an  anaesthetic  career  of  thirty  years 
I  can  recall  only  a  few  patients  to  whom  I  have  refused 
to  administer  an  anaesthetic  and  the  contra-indication 
in  each  case  has  usually  been  the  psychical  condition 
of  the  patient. 


40  General  Ancesthetics  in  Dentistry, 


LECTURE  IV. 

Elements  of  Danger. 

The  elements  of  danger  surrounding  the  adminis- 
tration of  general  anaesthetics  may  be  classified  as 
follows : 

First:  Ignorance,  inexperience,  and  carelessness  on 
the  part  of  the  anaesthetist, 

Second:  Length  of  duration  of  the  anaesthesia  induced. 

Third :  Physical  condition  of  the  patient  to  be  anaes- 
thetized. 

Fourth :  Shock. 

In  civic  matters,  ignorance  of  the  law  excuses  no 
man.  Hoav  important  it  is,  then,  that  the  anaesthetist, 
who,  for  the  time  being,  takes  the  life  of  the  patient 
into  his  own  keeping  and  is  responsible  for  it,  should 
surround  himself  with  all  the  safeguards  and  knowl- 
edge pertaining  to  this  subject.  One  must  familiarize 
himself  with  the  various  anaesthetic  symptoms — to  do 
less  is  criminal.  It  will  be  shown  that  deaths  during 
anaesthesia  are  the  result,  in  nearly  all  cases,  of  oper- 
ating too  soon,  before  the  patient  is  properly  anaes- 
thetized ;  or  operating  too  long,  while  the  patient  is 
coming  out  of  the  anaesthetic;  or  the  anaesthesia  in- 


General  Aiiccsthetics  in  Dentistry.  41 

duced  is  not  sufficiently  profound  to  avoid  shock, 
hence  the  paramount  importance  of  knowing  anaes- 
thetic symptoms.  Ignorance  in  these  matters  has 
resulted  in  sending  thousands  of  patients  to  unneces- 
sary graves. 

Medical  and  dental  colleges  are  at  serious  fault  in 
that  they  do  not  compel  their  students  to  administer 
anaesthetics  frequently,  in  the  presence  of  competent 
instructors.  It  has  been  said  that  "The  student  can 
learn  to  administer  anaesthetics  after  leaving  school." 
The  same  could  be  said  of  the  porcelain  inlay  or  the 
gold  filling.  The  general  public  expect  graduate  den- 
tists to  do  well  what  they  undertake  to  do,  but,  in  the 
matter  of  general  anaesthetics,  the  dental  surgeon  must 
learn,  if  at  all,  on  his  own  patients  in  his  own  office. 
You  can  not  become  a  competent  anaesthetist  by 
simply  looking  on.  You  must  take  the  inhaler  in  your 
own  hand;  feel  the  responsibility  of  the  patient's  life; 
test  the  pulse  for  yourself;  watch  the  breathing  and 
study  the  pupillary  movements.  Not  knowing  the 
anaesthetic  stages,  the  tyro  becomes  alarmed  at  harm- 
less symptoms,  entirely  overlooking  the  quiet  danger 
signals.  He  is  inclined  to  operate  too  soon  or  too 
long,  and  thus  makes  a  failure,  bringing  into  disrepute 
some  worthy  appliance,  and  condemns  anaesthetics  for 
dental  purposes,  simply  because  he  is  ignorant  of  both 
the  principles  and  practice  of  anaesthetics. 

In  January,  1905,  I  stepped  into  the  office  of  a 
dental  acquaintance  in  a  Colorado  city,  and  found  him 
engaged  in  a  boisterous  conversation  with  a  young 
man,  threatening  to  throw  him  out  of  the  window  if 


42  General  Ancrsthefics  in  Dentistry. 

he  did  not  leave  the  room  instantly.  I  was  astonished 
at  the  temper  exhibited  and  the  language  used  by  this 
usually  mild  Christian  gentleman.  Inquiry  brought 
out  the  cause  of  the  disturbance.  I  learned  that  the 
young  man  who  made  his  exit  so  hurriedly  on  my 
entrance  to  the  office  was  an  agent  demonstrating  one 
of  the  newer  anaesthetics.  Upon  assuring  the  dentist 
that  the  anaesthetic  in  question  was  pleasant  to  take, 
harmless  to  a  certainty,  profound  enough  in  its  action 
to  prevent  pain,  and  was  followed  by  no  unpleasant 
results,  he  was  permitted  to  administer  it  to  a  patient 
belonging  to  one  of  the  wealthiest  and  most  aristo- 
cratic families  of  the  town — one  of  the  doctor's  choicest 
patients.  The  dentist  proceeded  to  operate  when  as- 
sured it  was  the  proper  time.  The  patient  was  only 
partially  anaesthetized.  A  scene  occurred  such  as  only 
those  who  have  witnessed  the  like  can  appreciate. 
Learning  the  hotel  at  which  the  young  man  was  regis- 
tered, I  called  on  him  and  asked  him  the  history  of  the 
occurrence.  He  said  this:  "I  am  not  a  dentist — only 
a  dental  salesman.  My  house  compels  me  to  go  from 
office  to  office  and  demonstrate  this  anaesthetic.  I 
have  no  right  to  administer  an  anaesthetic,  and,  if  a 
death  should  occur,  I  know  that  I  will  be  sent  to  the 
penitentiary.  I  am  deadly  afraid  of  the  stuff,  and, 
rather  than  make  a  mistake  and  give  too  much,  I  had 
the  doctor  operate  too  soon,  with  the  result  you  wit- 
nessed." Are  you  surprised  that  dentists  make  fail- 
ures and  are  unable  to  get  satisfactory  results,  when 
all  that  many  of  them  know  about  the  subject  is  what 
they  see  at  an  occasional  clinic  or  learn  from  some 


General  Anccsthctics  in  Dentistry.  43 

salesman  demonstrator,  whose  sum  total  of  knowledge 
of  ansesthetics,  their  action  and  danger,  is  usually  no 
greater  than  that  of  the  man  mentioned? 

Dental  colleges  arc  strict  in  their  requirements  in 
regard  to  all  other  studies  in  their  curriculum,  requir- 
ing so  many  points  in  gold  fillings,  so  many  in  amal- 
gam, so  many  in  crown  and  bridge  work,  the  requisite 
number  in  orthodontia,  etc.,  but,  when  it  comes  to 
anaesthetics,  the  only  study  in  the  course  in  which  the 
life  of  the  patient  is  involved,  they  are  satisfied  to  have 
some  one  make  an  occasional  demonstration,  the  stu- 
dents looking  on.  A  Chicago  dentist  in  the  American 
Dental  Journal  for  October,  1906,  has  this  to  say: 
"Why  do  some  dentists  have  trouble  in  administering 
anaesthetics?  Because  students  are  graduated  from 
our  schools  with  the  theory  only  and  not  the  prac- 
tical experience.  A  few  days  ago  I  had  occasion  to 
meet  one  of  the  graduates  of  1906  from  one  of  the 
schools  in  this  city.  I  asked  him  what  experience  he 
had  in  administering  anaesthetics  during  his  college 
course.  He  said  that  he  had  the  best  of  theory,  but 
scarcely  any  experience.  'How  many  times  did  you 
administer  or  assist  the  demonstrator  with  chloroform, 
ether  or  nitrous  oxid,  or  how  many  times  did  you  see 
these  anaesthetics  administered?'  He  said:  'I  never 
assisted  or  saw  these  ana?stlietics  started.'  I  asked 
him  if  there  had  been  any  operations  performed  under 
anaesthetics.  He  said :  'Yes,  but  in  all  the  operations 
that  I  witnessed  the  patient  was  anaesthetized  before 
being  brought  into  the  pit.'  'How  many  administra- 
tions was  each  student  required  to  give  with  the  assist- 


,44  General  Anccsthetics  in  Dentistry. 

ance  of  the  demonstrator  ?'  'A  student  was  not  allowed 
to  administer  an  anaesthetic ;  it  was  always  done  by  a 
demonstrator.'  " 

Such  carelessness,  almost  criminal,  is  equalled  only 
by  our  medical  schools.  Even  in  our  best  hospitals,  in- 
ternes, selected  from  the  class  just  graduated,  become 
anaesthetists  over  night,  and  assume  entire  charge  of 
the  anaesthetic  work.  It  is  a  burning  shame  that  every 
hospital  has  not  a  professional  anaesthetist,  so  that  this 
work  may  not  be  left  to  inexperienced  men. 

Anaesthetics  in  themselves  are  not  so  dangerous  as 
the  fact  that  medical  men  are  turned  loose  on  the  pub- 
lic without  practical  experience  in  administering  anaes- 
thetics, and  dental  graduates  administer  anaesthetics 
without  even  as  much  experience  as  our  medical 
brothers.  Notwithstanding  this  condition  of  affairs, 
the  percentage  of  deaths  during  anaesthesia  is  not  high, 
and  I  will  show  in  a  later  lecture  that  a  number  of 
cases  have  been  included  for  which  the  anaesthetic  was 
in  no  way  responsible. 

Some  months  ago  I  had  a  difficult  third  molar  oper- 
ation at  one  of  the  Iowa  hospitals.  The  patient  took 
the  anaesthetic  badly ;  indeed,  at  no  stage  of  the  opera- 
tion did  the  anaesthetist  succeed  in  producing  a  pro- 
found anaesthesia — it  seemed  impossible  even  to  obtain 
that  depth  of  anaesthesia  which  insures  safety  and 
comfortable  operating.  In  all  twenty-four  ounces  of 
ether  were  inhaled  and  wasted.  A  surgeon  in  an  ad- 
joining room  in  less  time  performed  a  hysterectomy, 
dressed  and  left  the  hospital.  About  a  month  later  I 
went  to  a  medical  college  in  the  same  town  to  give  a 


General  Anesthetics  in  Dentistry.  45 

clinic  and  met  there  a  young  man  whose  face  was  very 
famlHar,  but  I  could  not  place  him.  I  inquired, 
"Where  have  I  met  you?"  He  replied,  "I  am  the  man 
who  administered  ether  for  you  at  the  hospital  not 
long  ago.  The  interne  was  away  on  his  vacation  and 
I  was  taking  his  place."  This  man  was  a  junior  medi- 
cal student.  One's  blood  boils  with  indignation  when 
subjected  to  sucli  imposition. 

The  interne  (juestion  is  an  important  one.  The  in- 
terne is  a  valuable  adjunct  to  the  hospital,  but  there 
should  be  a  professional  anjesthetist  at  every  hospital, 
whose  duty  it  should  be  to  carefully  diagnose  all  anaes- 
thetic cases  in  advance  of  the  operation  and  determine 
the  anaesthetic  to  be  employed.  The  interne  should 
work  under  and  in  conjunction  with  the  chief  anaes- 
thetist and  not  have  the  entire  responsibility  of  the 
anaesthetic  cases.  The  service  of  an  interne  is  from 
six  months  to  two  years ;  they  are  constantly  chang- 
ing; new  men  take  up  the  work  and  with  it  the 
anaesthetic  responsibilit}'. 

Many  lives  have  been  sacrificed  during  anaesthesia 
because  the  anaesthetist  became  so  absorbed  in  the 
operation  as  to  neglect  the  patient.  The  tendency  and 
the  temptation  always  is  to  watch  the  operation,  and, 
for  this  reason,  the  anaesthetic  specialist  or  the  profes- 
sional anaesthetist  who  has  no  intention  of  becoming  a 
surgeon  or  an  operator  renders  superior  service. 

Women  make  the  best  anaesthetists.  They  natu- 
rally shrink  from  operative  procedure,  care  nothing 
about  it,  and  bestow  their  undivided  attention  on  the 
patient.     There  is  no  place  in  the  world  where  they 


46  General  Ancesthetics  in  Dentistry. 

get  such  wonderful  anaesthetic  results  as  at  the  Mayo 
Clinic,  Rochester,  Minn.,  and  the  anaesthetists  are  all 
women.  Alice  Magaw,  the  most  successful  anaesthet- 
ist I  have  ever  known,  reigns  supreme  at  Rochester. 
To  say  that  she  has  a  record  of  more  than  18,000  ether 
anaesthesias  without  an  accident  in  1908  does  not  tell 
the  whole  story.  She  is  masterful  in  handling  pa- 
tients, and  with  an  amount  of  anaesthetic  that  hardly 
sounds  reasonable,  in  so  brief  a  time,  you  would  hardly 
believe  the  statement,  tactfully,  skilfully  induces 
anaesthesia. 

It  is  claimed  that  the  instruction  in  general  anaes- 
thetics in  dental  colleges  is  meagre  and  not  practical ; 
the  same  may  be  said  of  the  medical  schools.  Unless 
the  medical  student  is  so  situated  that  he  can  take  a 
post-graduate  hospital  course,  or  become  an  interne, 
not  one  in  ten  ever  administers  an  anaesthetic  until 
after  graduation  and  entering  practice.  It  is  probably 
true  that  anaesthetics  receive  less  attention,  in  both 
medical  and  dental  colleges,  than  any  other  subject  in 
the  curriculum,  and  this  is  so,  not  only  in  this  country, 
but  abroad,  as  the  following  quotation  from  the  British 
Medical  Journal  will  show :  Dudley  W.  Buxton,  the 
renowned  English  authority  on  anaesthetics,  says,  "At 
present  there  is  no  uniform  teaching  on  anaesthetics." 
He  suggests  that  a  resolution  be  passed  by  the  general 
medical  council  compelling  all  medical  students,  before 
applying  for  final  examination,  to  ofifer  evidence  of 
having  attended  the  practice  of  some  recognized  anaes- 
thetist. He  should  also  ofifer  proof  of  having  admin- 
istered nitrous  oxid,  ether  and  chloroform."    Galloway 


General  Aiucsihetics  in  Dentistry.  47 

calls  attention  to  the  common  carelessness  in  regard 
to  the  use  of  anaesthetics.  He  claims  that  if  unneces- 
sary deaths  occur  from  anaesthetics  the  responsibility 
extends  beyond  the  anaesthetizer  and  includes  the 
medical  college  which  ignores  its  importance,  makes 
no  effort  to  teach  it  properl}-,  if  at  all,  and  then  confers 
a  diploma  which  the  public  accepts  as  the  evidence  of 
a  training  which  the  student  really  has  not  received. 
The  criticism  is  just,  that  the  dental  colleges  are  not 
devoting  as  much  time  to  practical  anaesthesia  as  they 
should,  and  the  same  criticism  is  equally  just  that 
medical  schools  are  almost  criminally  negligent  in 
their  carelessness  about  anaesthetics. 

I  am  confident  that  if  medical  schools  demanded 
as  thorough  a  course  of  practical  training  in  anaes- 
thetics as  they  do  in  the  dissecting-room  in  anatomy, 
in  their  laboratories  in  histology,  pathology,  and  chem- 
istry, and  if  dental  colleges  would  insist  on  an  anaes- 
thetic technic  as  they  have  done  in  operative  and  pros- 
thetic dentistry  and  orthodontia,  the  percentage  of 
deaths  could  be  reduced  fifty  per  cent,  in  ten  years' 
time. 

Length  of  Duration  of  Anaesthesia. 

Other  things  being  equal,  a  brief  anaesthesia  is  safer 
than  a  prolonged  antesthesia.  The  anaesthetist  feels 
less  anxiety  when  an  anaesthesia  of  ten  minutes  is  to 
be  induced  than  when  it  is  necessary  to  obtain  an 
anaesthesia  of  two  hours  or  more  for  the  same  patient. 
The  dental  surgeon  is  fortunate  in  that  nearly  all  the 
operations  he  is  called  upon  to  perform  arc  of  brief 


48  ^    General  Ancesthetics  in  Dentistry. 

duration,  and  a  general  angesthetic,  properly  selected 
and  administered,  would  be  less  harmful  to  the  patient 
than  the  effect  of  the  pain  on  the  nervous  system 
without  an  anaesthetic. 

With  the  exception  of  badly  impacted  third  molars, 
antrum  cases,  cleft  palate,  resection  of  a  nerve  for 
neuralgia,  necrotic  conditions,  and  tumor  formations, 
all  of  which  really  belong  to  the  oral  surgeon,  the 
dental  surgeon  seldom  needs  a  profound  anaesthesia  of 
more  than  five  minutes'  duration  for  any  operation 
that  he  is  called  upon  to  perform. 

If  it  be  true  that  chloroform  is  a  protoplasmic 
poison,  and  ether  a  nephritic  irritant,  the  brevity  of 
anzesthesia  for  dental  operations  would  eliminate  the 
probability  of  harm  from  these  conditions,  because 
deleterious  effects  would  result  only  from  a  prolonged 
anaesthesia. 

While  brief  anaesthesia  is  not  synonymous  with 
brief  induction,  it  does,  imply  brief  elimination.  The 
quicker  the  elimination  of  a  general  anaesthetic  from 
the  system,  the  speedier  the  return  of  all  functions  to 
the  normal.  If  brief  elimination  is  to  be  desired, 
brief  induction  is  ec[ually  to  be  desired,  and  we  ap- 
proach the  ideal  anaesthetic.  In  other  words,  the 
patient  should  be  in  the  anaesthetic  state  the  least  pos- 
sible length  of  time  for  successful  performance  of  the 
operation  in  question,  and  the  quicker  the  induction, 
and  quicker  the  elimination,  the  better  for  all  parties 
concerned ;  provided,  of  course,  the  anaesthetic  agent 
is  a  safe  one.  Herein  lies  the  safety  and  advantage  of 
nitrous  oxid  and  somnoform.    You  can  creep  up,  as  it 


General  Anesthetics  in  Dentistry.  49 

were,  on  the  brain  and  nervous  system,  anaesthetize 
them,  operate,  and  the  patient  return  to  consciousriess, 
ahnost  before  the  central  nervous  system  realizes  that 
an  anaesthetic  has  been  employed.  Such  operations 
as  I  have  outlined  in  the  second  lecture  can  be  per- 
formed under  the  influence  of  nitrous  oxid  and  oxygen 
or  somnoform,  the  anaesthesia  gently  maintained,  not 
so  deep  as  for  extraction  of  teeth,  but  only  to  the  stage 
of  unconsciousness.  The  obtundent  or  analgesic  stage 
is  sufificient  to  allay  all  fear  on  the  part  of  the  patient 
and  prevents  that  worn-out,  all-gone  feeling  of  ex- 
haustion and  fatigue  during  and  subsequent  to  dental 
operations. 


50  General  Ancesthetics  in  Dentistry. 


LECTURE  V. 
Shock. 

The  fourth  classification  under  Elements  of  Danger 
is  that  condition  which  causes  more  deaths  during  an- 
aesthesia than  all  other  accidents  combined,  namely, 
shock.  By  shock,  we  mean  depression.  We  have  de- 
pression of  respiration,  or  respiratory  shock;  depres- 
sion of  the  circulation,  or  circulatory  shock.  Hewitt 
goes  further  and  adds  what  he  calls  composite  shock; 
i.  e.,  respiratory  shock  rapidly  followed  by  circulatory 
depression,  or  circulatory  shock  rapidly  followed  by 
respiratory  depression. 

It  is  difficult  to  formulate  an  intelligent,  scientific 
definition  of  shock.  Nearly  ever}^  writer  on  this  sub- 
ject has  a  definition  of  his  own,  which  definition  does 
not  meet  the  approval  of  any  other  writer ;  hence,  there 
are  a  multitude  of  definitions,  but  a  lack  of  unanimity 
of  thought,  which  is  confusing  and  unsatisfactory. 
Taking  into  consideration  the  causes  of  shock  and  com- 
bining these  with  the  manifestations  of  shock,  the  con- 
dition is  defined.  A  patient  in  a  condition  of  shock  is 
quiet ;  the  mucous  membrane  is  pale ;  the  temperature 
frequently  below  normal;  the  pulse  rapid,  but  weak; 
the  blood  pressure  low;  the  cutaneous  reflexes  dimin- 
ished or  abolished;  respiration  shallow;  skin  cold  and 


General  Anccsthetics  in  Dentistry.  51 

clammy ;  increased  respiration ;  increased  perspiration ; 
the  action  of  the  mind  slow  or  dazed ;  neither  dehrium 
or  hysteria  is  present;  no  nervousness;  pupil  some- 
what dilated  and  responds  feebly  to  light.  These  are 
the  conditions  we  find  present  in  shock  to  a  less  or 
greater  degree. 

Now  as  to  the  causes  of  shock.  The  causes  are 
numerous,  but  they  act  in  each  case  by  stimulating 
the  afferent  nerves,  and,  if  these  nerves  are  stimulated 
too  suddenly,  too  frequently,  too  painfully,  too  forcibly, 
or  in  a  too  prolonged  degree,  shock  supervenes. 

Shock,  then,  may  be  defined  as  a  condition  of  de- 
pression, produced  by  exhaustion  of  the  medullary 
centers  controlling  respiration  and  circulation,  by  a  too 
sudden,  too  frequent,  too  painful,  too  forcible  or  too 
prolonged  stimulation  of  the  afferent  nerves,  "the  es- 
sential phenomenon  being  a  diminution  of  the  blood 
pressure." 

For  the  sake  of  convenience,  we  may  classify  pa- 
tients suffering  from  shock  into  two  groups : 

l^'irst :  Psychical,  those  affected  by  mental  impressions. 

Second  :  Physical,  those  in  which  shock  is  dependent 
upon  too  sudden,  too  frequent,  too  painful, 
too  forcible,  or  too  prolonged  stimulation  of 
the  afferent  nerves. 

In  the  first  group,  .the  psxchical,  those  who  are 
affected  by  mental  impressions,  fear  is  the  etiological 
factor  to  be  dealt  with — fear  or  dread  of  the  operation  ; 
fear  or  dread  of  the  anaesthetic,  if  one  is  suggested. 


52  General  Anccsthetics  in  Dentistry. 

The  dental  surgeon  meets  and  must  combat  this  con- 
dition daily.  Not  long  ago,  a  patient  to  whom  I  had 
just  administered  an  anaesthetic  for  tooth  extraction 
told  me  that  on  a  former  occasion,  while  sitting  in  a 
dentist's  chair,  the  dread  of  having  used  a  local  an- 
aesthetic was  so  terrifying,  that  before  the  dentist  had 
time  to  make  the  injection,  she  fainted  and  for  two 
hours  was  in  a  most  critical  condition.  It  was  only  the 
assurance  that  I  could  operate  absolutely  painlessly, 
that  gave  her  sufficient  confidence  to  take  the  an- 
aesthetic. 

Dr.  McClanahan,  of  Iowa  Falls,  Iowa,  told  me  that 
he  had  a  similar  experience,  except  that  he  was  to  make 
an  examination  of  the  teeth,  not  to  extract.  He  turned 
to  his  instrument  case  a  moment,  and,  upon  resuming 
his  position  at  the  chair,  his  patient  was  pale,  gasping 
for  breath,  had  lost  consciousness,  and  it  was  three 
hours,  assisted  by  physicians,  before  she  was  resusci- 
tated. 

While  writing  the  above  sentence,  the  postman 
brought  the  mail,  leaving  a  sample  copy  of  D.  D.  S. 
for  September-October,  1907.  The  first  article  is  en- 
titled 

"Death   From   Shock. 

"Since  our  last  issue  a  Dayton  dentist  has  had  one 
of  those  experiences  that  are  so  trying  to  the  mem- 
bers of  our  profession — namely,  a  death  in  his  chair 
while  engaged  in  performing  his  regular  duties. 

"A  young  woman  applied  to  him  for  the  extraction 
of  a  tooth.     There  was  nothing  about  her  condition 


General  Anesthetics  in  Dentistry.  53 

that  would  indicate  that  she  was  not  in  average  health, 
and  the  dentist  prepared  to  relieve  her  of  the  offending 
member, 

"There  were  reasons  that  seemed  entirely  satis- 
factory to  him  why  a  general  anaesthetic  need  not  be 
given,  though  he  is  expert  in  the  use  of  somnoform, 
neither  was  he  prompted  to  inject  the  tissues  with  a 
local  anaesthetic.  Instead  of  these  he  saturated  a 
pledget  of  cotton  with  an  anodyne,  applied  it  over  the 
gum,  then  proceeded  with  the  extraction.  The  tooth 
was  a  lower  bicuspid  and  showed  no  unusual  difficulty 
in  removal. 

"No  sooner  had  it  been  lifted  from  its  socket  than 
the  woman's  body  was  noticed  to  relax,  her  head  fell 
forward  upon  her  chest,  and  her  breathing  ceased.  Ex- 
amination disclosed  a  pulseless  wrist. 

"In  the  next  room  was  a  physician  who  was  imme- 
diately summoned.     ******* 

"They  did  everything  that  a  competent  physician 
and  skilled  dentist  could  do  without  accomplishing 
anything. 

"You  ask  the  cause?  It  was  shock.  The  dread  and 
fright  of  the  extraction  started  an  impulse  that  prob- 
ably contracted  the  circulatory  vessels  of  the  vaso- 
motor centers  in  the  medulla  which  in  turn  so  greatly 
interfered  with  the  action  of  the  pneiimogastric  nerve 
that  the  heart  and  lungs  ceased  to  act.     *     *     *     *" 

A  man  went  to  a  hospital  in  England  to  visit  his 
father  who  was  mortally  ill.  After  leaving  the  hospital, 
he  dropped  dead  a  hundred  yards  from  the  gate  from 
mental  emotion.     There  was  a  post-mortem  of  both 


54  General  Anccsthetics  in  Dentistry. 

next  day,  the  father  dying  from  disease  in  the  hospital, 
the  son  from  shock  at  the  hospital  gate.     (Brunton.) 

A  patient  was  being  anaesthetized  for  an  abdominal 
operation.  The  surgeon,  standing  with  his  knife  in 
hand,  awaiting  the  signal  to  operate,  with  the  point 
of  the  handle  traced  the  place  and  length  of  incision 
he  would  make — the  patient  died  immediately.  Suffi- 
ciently anaesthetized  to  be  rendered  helpless,  yet  con- 
vinced that  the  surgeon  was  beginning  the  operation, 
shock  resulted,  and  the  patient  died.  This  was  recorded, 
of  course,  as  a  death  from  anaesthesia.  Dr.  Schofield, 
in  his  recent  work  on  "The  Subconscious  Mind,"  re- 
lates a  case  which  occurred  in  England.  A  man  was 
condemned  to  the  death  penalty ;  his  head  was  on  the 
block  awaiting  the  fall  of  the  axe,  when  he  was  re- 
prieved; but  he  was  found  to  be  already  dead  from 
shock. 

The  French  surgeons  report  this  case :  A  patient 
was  to  be  operated  upon,  and  his  condition  contra-indi- 
cated the  administration  of  general  anaesthetics;  but 
he  demanded  chloroform,  and,  to  calm  him,  the  sur- 
geon held  a  cloth  without  chloroform  before  his  face. 
The  patient  had  taken  but  four  inhalations  of  air, 
when  he  died. 

A  gentlenaan  was  sitting  in  the  chair  of  a  Parisian 
dentist,  mouth-prop  inserted,  ready  to  have  admin- 
istered nitrous  oxid.  The  operator,  the  inhaler  in 
hand,  turned  aside  to  signal  the  assistant  to  turn  on 
the  nitrous  oxid;  resuming  his  position  at  the  chair  to 
make  the  administration,  found  the  patient  dead.    Had 


General  Anesthetics  in  Dentistry.  55 

this  patient  taken  even  one  inhalation  of  the  gas,  it 
would  have  been  recorded  as  a  nitrous  oxid  gas  death. 

Just  recently  at  Ackley,  Iowa,  a  horse  was  tied  to 
a  post  near  a  railroad  track.  An  engine  came  thun- 
dering along  at  a  rapid  speed,  and,  when  opposite  the 
horse,  the  whistle  gave  a  tremendous  shriek.  The 
horse  reared,  plunged  forward  and  fell  dead  from 
fright — shock. 

In  the  second,  the  physical,  we  classify  those  cases 
of  shock  which  are  dependent  upon  too  sudden,  too 
frequent,  too  painful,  too  forcible,  or  too  prolonged 
stimulation  of  the  afferent  nerves.  While  the  psychical 
equation  is  also  present  in  this  second  group,  and  in 
many  cases  cannot  be  eliminated,  yet  it  is  the  more 
tangible  causes  of  shock,  those  which  may  be  denom- 
inated exciting  causes,  that  will  be  taken  into  consid- 
eration. The  etiological  factor  in  this  group  is  some 
physical  irritant. 

In  reporting  mortalities  resulting  from  chloroform 
anaesthesia,  it  is  frequently  said  that  the  patient  died 
after  the  first  two  or  three  inhalations..  Some  of  these 
deaths  are  the  result  of  mental  impressions,  fear;  others 
from  direct  irritation  of  the  sensory  nerves  of  the  nares, 
pharynx,  bronchi  or  lungs.  Some  writers  are  of  the 
opinion  that  nearly  all  of  the  chloroform  mortalities 
that  occur  from  just  a  few  inhalations -of  the  anaesthetic 
are  purely  psychic.  If  this  were  true,  deaths  would 
more  frequently  occur  at  the  very  beginning  of  the  ad- 
ministration of  other  anrcsthctics.  We  know  that  a 
handkerchief  on  which  has  been  placed  chloroform, 
and  even  aqua  ammonia,  held  under  the  nose  of  a  rab- 


56  General  Ancssthetics  in  Dentistry. 

bit,  will  cause  its  heart  to  cease  beating.  The  wonder 
is  there  are  not  many  more  chloroform  mortalities 
when  we  take  into  consideration  the  careless  manner 
in  which  chloroform  is  administered.  It  only  takes 
two  per  cent,  of  chloroform  vapor  to  anaesthetize  a 
patient  and  one  per  cent,  is  sufficient  to  maintain  anaes- 
thesia, but  this  is  either  not  well  understood  or  is  not 
believed,  because  during  an  average  anaesthesia,  many, 
many  times  this  amount  of  chloroform  is  usually  em- 
ployed. All  those  deaths,  that  occur  during  the  first 
minute  or  two  of  chloroform  anaesthesia  are  the  result 
of  shock,  either  from  the  first  cause  assigned,  fear,  or 
the  second,  by  too  suddenly  irritating  the  afferent 
nerves. 

If  chloroform  is  administered  in  a  very  dilute  form, 
and  gently,  we  get  no  shock  in  either  plants  or  animals, 
as  Sir  James  Y.  Simpson  has  demonstrated.  He  made 
some  very  interesting  experiments  on  that  most  deli- 
cate of  all  plants,  the  sensitive  plant,  the  mimosa 
pudica.  If  you  touch  the  leaves  of  the  sensitive  plant, 
they  at  once  fold  up  and  fall  down  upon  the  stock.  Sir 
James,  who  discovered  the  anaesthetic  properties  of 
chloroform,  found  that  if  you  subject  this  plant  to  the 
strong  vapor  of  chloroform,  the  leaves  would  close  up 
just  as  if  you  had  irritated  them  in  an)^  other  way.  But 
if  you  apply  a  very  dilute  chloroform  vapor,  you  can 
now  handle  the  sensitive  plant  and  it  does  not  irritate 
or  cause  it  to  fold  up.  In  other  words,  it  has  been 
anaesthetized  by  the  mild  vapor  without  irritation, 
while  the  strong  vapor  produced  shock  and  defeated 
anaesthetization.    The  mild  vapor  does  not  produce  any 


General  Ancusthetics  in  Dentistry.  57 

irritation  whatever,  simply  produces  anaesthesia.  The 
same  is  true  of  the  rabbit  and  the  guinea-pig — diluted 
chloroform  vapor  produces  anaesthesia  without  irri- 
tation, but,  if  a  strong  vapor  is  used  suddenly,  it  will 
irritate  the  vagus  reflexly  through  the  fifth  nerve  and 
the  respiration  will  cease ;  what  is  true  of  plants  and 
animals  holds  good  in  that  higher  animal,  man. 

The  irritating  general  anaesthetics,  then,  should  be 
administered  in  dilute  form,  starting  with  just  a  trace 
of  vapor,  and  gradually  increasing  the  strength  as  the 
nerves  along  the  respiratory  channel  become  accus- 
tomed to  the  anaesthetic,  or  are  themselves  locally 
anaesthetized. 

There  is  a  form  of  shock  that  results  from  blows 
or  external  pressure.  A  blow  suddenly  delivered  upon 
the  abdomen  or  about  the  heart  sometimes  produces 
death  from  nervous  shock  affecting  the  solar  plexus. 
If  I  remember  correctly,  it  was  a  blow  received  in 
the  stomach  of  Corbett,  delivered  by  Bob  Fitzsimmons, 
that  "knocked  him  out";  a  little  harder  blow  would 
have  completely  paralyzed  the  solar  plexus  and  ended 
the  life  of  Air.  Corbett. 

Before  the  introduction  of  general  anaesthetics,  the 
methods  used  to  induce  anaesthesia  were  peculiar  and 
almost  ludicrous.  One  method  was  for  three  strong 
men  to  stand  on  each  side  of  the  patient,  who  was 
placed  in  the  recumbent  ])osition,  and  at  a  given  signal 
the  patient  was  raised  quickly  to  the  standing  position. 
The  head  was  raised  quicker  than  the  blood  could  fol- 
low it,  and  this  temporary  anaemia  of  the  brain  brought 
about   a   faint,  during  the   continuance   of  which   the 


58  General  Ancssthetics  in  Dentistry. 

operation  was  performed.  It  was  proposed  by  the  late 
physiologist,  Dr.  Waller,  to  produce  ansesthesia  not  by 
simply  raising  the  man,  but  by  garrotting  him,  simply 
putting  the  finger  and  thumb  upon  the  carotid  ar- 
teries, compressing  them  suddenly,  and  thus  rendering 
the  patient  insensible ;  but  the  introduction  of  anaes- 
thetics prevented  either  of  these  plans  from  having  a 
very  wide  use.  (Brunton.)  This  sudden  compression 
of  the  carotids  to  produce  insensibility  is  one  of  the 
jiu  jitsu  tricks  of  the  Japanese.  A  person  is  rendered 
immediately  insensible  by  shock,  and,  if  the  force  be 
applied  too  vigorously,  the  patient  does  not  revive. 

Most  persons  killed  by  hanging  or  strangling  die 
from  shock,  not  sufifocation.  A  sudden  pressure  on  the 
larynx  and  trachea  causes  reflexly,  through  the  nervous 
system,  a  sudden  stoppage  of  the  heart  and  lungs.  It 
is  not  that  the  respiration  ceases  and  the  heart  con- 
tinues its  action,  as  in  suffocation,  but  the  heart  and 
lungs  both  cease  to  perform  their  functions.  It  is  said 
that  more  than  half  of  the  people  who  die  from  falling 
into  water  are  not  drowned;  they  do  not  die  from 
suffocation,  but  from  shock.  (Brunton.)  They  are 
either  frightened  to  death,  or  the  sudden  shock  of 
falling  into  cold  water  acts  reflexly,  and  both  respira- 
tion and  circulation  are  discontinued. 

External  pressure  plays  such  an  important  part  in 
the  production  of  shock  that  every  possible  precaution 
should  be  taken  in  administering  anaesthetics  to  pre- 
vent the  slightest  pressure  on  the  throat,  lungs,  chest 
or  abdomen.  The  position  of  the  patient  has  much  to 
do  with  the  pressure  on  the  parts  mentioned.     A  pa- 


General  Anesthetics  in  Dentistry.  59 

tient,  who,  in  the  standing  position,  thinks  her  corset 
quite  loose,  upon  taking  her  seat  in  the  dental  chair, 
through  readjustment  of  the  abdominal  organs,  finds 
the  corset  very  tight,  and  the  fatter  the  patient  the 
more  she  spreads  out  in  the  sitting  posture.  There  is 
only  one  safe  method  of  procedure ;  that  is,  refuse  ab- 
solutely to  anaesthetize  any  woman  unless  the  corset 
is  removed  no  matter  what  anaesthetic  is  employed. 

The  same  is  true,  in  a  lesser  degree,  of  all  bands 
and  collars,  loose  enough,  perhaps,  in  the  upright  posi- 
tion, but  the  patient  under  anaesthesia  may  slide  into 
a  position  that  will  render  the  collar  and  band  ex- 
tremely tight  without  the  anaesthetist  observing  it. 
Even  should  no  dangerous  symptoms  arise  from  oper- 
ating without  removing  the  corset  and  collar,  I  am 
satisfied  that  most  of  the  nausea  occurring  in  dental 
chairs  during  or  as  the  result  of  administering  nitrous 
oxid  and  somnoform  is  the  result  of  tight  clothing. 
No  woman  is  as  easily  and  as  successfully  anaesthetized 
in  tight  clothing  as  in  loose  clothing,  and  most  of  the 
failures  to  successfully  and  comfortably  anaesthetize 
patients  is  the  result  of  carelessness  or  ignorance,  on 
the  part  of  the  dental  surgeon,  in  regard  to  properly 
arranging  the  patient  for  the  operation.  If  it  should 
become  necessary  to  resort  to  resuscitory  measures, 
the  corset  is  always  in  the  way,  and  the  patient  might 
die  before  you  could  free  the  muscles  of  respiration 
or  massage  the  muscles  about  the  heart. 

Spasm  of  the  glottis  is  the  condition  to  which  I 
■will  next  call  your  attention.  Bear  in  mind  that  spasm 
of  the  glottis  may  arise  at  the  very  beginning  of  the 


60  General  Anccsthetics  in  Dentistry. 

administration  of  an  anaesthetic,  through  carelessness, 
if  the  vapor  be  too  strong;  and  at  the  conclusion  of  the 
anaesthetic,  from  the  accumulation  of  blood,  mucus, 
vomit,  etc.,  in  the  larynx.  Spasm  of  the  glottis  is 
the  condition  that  gives  me  the  most  anxiety  in  my 
anaesthetic  work.  It  is  the  condition  that  I  ever  bear 
in  mind  in  administering  anaesthetics,  the  condition 
for  which  I  watch  most  closely  and  constantly.  As  I 
have  previously  said,  this  condition  may  arise  at  the 
beginning  of  anaesthesia,  and  in  operations  in  the 
mouth,  nose  and  pharynx,  at  the  close  of  or  during  the 
operation.  When  it  occurs  at  the  beginning  of  an- 
aesthesia, it  usually  arises  from  too  suddenly  or  too 
powerfully  stimulating  the  sensory  nerves  along  the 
respiratory  tract.  The  cases  we  have  just  been  con- 
sidering, those  in  which  patients  died  after  taking  but 
two  or  three  inhalations  of  the  anaesthetic,  were  deaths 
from  spasm  of  the  glottis.  The  remedy  has  already 
been  suggested :  begin  the  anaesthesia  with  a  very 
dilute  anaesthetic-laden  vapor,  the  patient  taking  nor- 
mal inhalations  in  the  beginning.  If  you  will  bear  in 
mind  constantly,  what  I  have  said  about  always  be- 
ginning with  a  dilute,  non-irritating  vapor,  you  will 
probably  never  see  a  case  of  spasm  of  the  glottis  in  the 
first  stages  of  anaesthesia.  Spasm  of  the  glottis,  oc- 
curring after  beginning  to  operate,  or  at  the  close  of 
the  operation,  is  a  very  different  matter.  I  watch  for 
this  condition  more  earnestly,  if  possible,  than  that 
form  of  spasm  of  the  glottis  which  results  from  faulty 
anaesthesia. 

We  will  next  discuss  spasm  of  the  glottis  occtif'fihg 


General  Ancesthetics  in  Dentistry.  61 

during  or  at  the  close  of  the  operation,  the  exciting 
cause  being  irritation  of  the  nares,  pharynx,  larynx,  or 
trachea,  the  result  of  blood,  mucus,  saliva,  vomit,  or 
other  foreign  matter  collecting  in  the  throat.  I  have 
stated  previousl}'  tiiat  the  one  condition  I  watched  for 
most  carefully,  and  the  one  that  caused  me  the  most 
anxiety  in  my  anaesthetic  v^^ork  was  the  passage  into 
and  a  collection  of  blood  in  the  throat,  lest  from  pres- 
sure or  interruption  of  respiration  the  vagus  be  irri- 
tated sympathetically  and  shock  result.  One  of  the 
brightest  young  dental  surgeons  Iowa  ever  produced 
met  his  death  from  shock,  the  result  of  blood  collecting 
in  the  throat  following  a  tonsilotomy. 

As  long  as  the  patient  swallows  freely,  there  is 
nothing  to  dread  ;  but  at  that  stage,  when,  with  some 
patients,  there  is  contraction  of  all  the  muscles  of  the 
body  and  a  stiffening  and  hardening  of  the  throat  mus- 
cles, a  serious  condition  may  arise.  In  this  condition, 
the  patient  can  neither  spit  nor  swallow,  and  it  is 
important  that  blood  be  prevented  from  entering  the 
throat.  Methods  of  preventing  blood  accumulating  in 
the  throat  are  fully  described  in  the  lecture  on  "Ele- 
ments of  Success." 

Eliminating  spasm  of  the  glottis,  blood  should  be 
prevented  from  entering  the  stomach,  because  it  nearly 
always  causes  nausea.  If  patients  are  not  nauscatetl  in 
the  ofifice,  they  arc  apt  to  be  nauseated  after  going 
home,  and  the  anaesthetic  is  usually  blamed  or  con- 
demned. Care  must  be  taken  to  prevent  teeth  or  roots 
of  teeth  from  entering  the  throat,  especially  the  larynx. 
Teeth  have  been  known  to  pass  into  the  pharynx,  enter 


62  General  Anccsthetics  in  Dentistry. 

the  trachea  and  produce  spasm  of  the  glottis,  making 
tracheotomy  necessary. 

Even  with  nitrous  oxid  and  somnoform,  when  pos- 
sible, have  your  patients  eat  only  moderately,  or  not  at 
all,  prior  to  anaesthesia.  Three  hours  after  eating  a 
meal  is  a  convenient  time  to  administer  these  anaes- 
thetics. Although  I  anaesthetize  patients  any  hour 
that  they  happen  to  come  with  nitrous  oxid  or  somno- 
form, if  I  have  the  privilege  of  making  an  appointment, 
I  select  the  hours  of  eleven  o'clock  in  the  morning  and 
between  three  and  four  o'clock  in  the  afternoon.  Al- 
though nausea  rarely  occurs  with  these  anaesthetics 
and  is  not  apt  to  happen,  yet  we  should  take  every 
precaution  to  prevent  it.  Should  nausea  occur  while 
the  patient  is  anaesthetized,  there  is  risk  of  undigested 
food,  from  its  presence  and  position,  causing  spasm  of 
the  glottis.  This  matter  was  forcibly  brought  to  my 
attention  on  an  occasion  when  I  was  administering 
nitrous  oxid  at  my  clinic,  before  a  large  class  of  stu- 
dents at  the  College  of  Dentistry,  State  University  of 
Iowa.  The  inhaler  which  I  was  accustomed  to  use  at 
this  clinic  refused  to  work;  as  a  substitute,  an  old  hard 
rubber  tube  which  passed  into  the  mouth  was  resur- 
rected, the  rubber  hood  falling  around  the  nose  and 
face.  With  this  hard  rubber  tube  in  the  mouth,  about 
an  inch  in  diameter,  it  did  not  occur  to  me  that  a 
mouth-prop  was  necessary.  I  proceeded  to  administer 
nitrous  oxid,  and  when  satisfied  that  the  patient  was 
sufficiently  anresthctized  for  the  operation,  removed 
the  inhaler  and  the  patient's  mouth  closed  with  the 
speed  and  force  of  an  old-time  muskrat  trap.     Imme- 


General  Anesthetics  in  Dentistry.  63 

diately  he  became  nauseated,  and  the  contents  of  his 
stomach,  undigested  food,  filled  his  nose,  mouth,  and 
pharynx.  His  face  became  purple,  then  black;  he 
ceased  to  breathe.  It  was  impossible  at  first  to  force 
his  jaws  apart.  W'e  bounced  him  up  and  down  in 
the  chair,  hoping  to  force  back  the  undigested  food. 
Fortunately,  two  front  teeth  were  missing.  I  inserted 
my  finder,  assistants  keeping  up  the  bouncing,  and 
some  air  must  have  entered  his  lungs,  for  at  this  stage 
of  the  resuscitation,  he  opened  his  mouth  and  dis- 
charged the  contents  of  his  stomach.  It  was  the  first 
and  only  alarming  condition  I  have  ever  witnessed  in 
my  anaesthetic  work.  This  experience  was  worth  more 
to  me  and  to  the  class  than  a  hundred  cases  in  which 
the  result  was  perfect.  I  was  at  fault,  first,  in  that  I 
did  not  use  a  stable  mouth-prop ;  second,  in  that  I  did 
not  inquire  how  long  it  had  been  since  the  patient  had 
eaten  his  last  meal.  The  hour  of  dinner  is  so  univer- 
sally noon  in  this  State,  and,  as  the  clinic  was  ar- 
ranged purposely  between  the  hours  of  three  and 
four,  I  did  not  make  the  usual  inquiry.  The  patient  , 
informed  me  afterwards  that  he  had  only  finished  his 
dinner  a  few  minutes  before  coming  to  the  clinic. 
We  came  very  nearly  having  a  fatality,  and  the  fault 
was  all  my  own.  Had  this  young  man  died,  his  death 
would  have  been  recorded  as  a  nitrous  oxid  death. 
Had  the  mouth-proj)  been  in  ])ositi(Mi,  he  would  simply 
have  lost  his  dinner,  and  the  case  forgotten  long  ago. 
When  ether  and  chloroform  are  the  anaesthetics  em- 
ployed, every  preliminary  precaution  known  should  be 
taken  to  prevent  nausea.     This  matter  of  preventing" 


64  General  Ancesthetics  in  Dentistry. 

nausea  as  the  result  of  ether  and  chloroform  anaes- 
thesia and  its  treatment  will  be  considered  in  another 
lecture. 

Another  cause  of  shock  is  operating  in  the  prelim- 
inary stages  when  anaesthesia  is  being  induced,  or  in 
the  later  stage  when  it  is  passing  off.  If  you  will  in- 
vestigate the  matter  ascertaining  at  what  time  during 
anaesthesia  deaths  occur,  you  will  discover  nearly  all 
the  fatalities  happen  during  partial  anaesthesia,  that 
very  seldom  is  a  mortality  reported  during  profound 
anaesthesia. 

Lauder  Brunton  speaks  of  having  witnessed  only 
one  death  under  anaesthetics.  It  was  a  man  who  was 
having  the  supra-maxillary  bone  removed  for  malig- 
nant disease,  and  the  whole  of  the  orbit  was  exposed. 
On  account  of  the  risk  of  blood  running  down  into  the 
trachea  and  choking  him  during  anaesthesia,  he  only 
had  a  few  drops  of  chloroform  at  the  beginning  of 
the  operation,  just  enough  to  allow  the  preliminary 
incision  to  be  made.  The  rest  of  the  operation  was 
conducted  without  any  anaesthetic,  and  the  man  died 
on  the  table  from  the  shock  of  the  operation. 

It  is  important,  even  in  the  matter  of  extracting 
teeth,  that  the  patient  be  sufficiently  anaesthetized  be- 
fore beginning  to  operate.  Do  not  begin  to  operate 
until  you  are  satisfied  that  pain  will  not  be  felt,  and 
be  sure  to  stop  extracting  before  the  patient  is  suffi- 
ciently awake  to  feel  pain.  In  my  early  professional 
experience,  I  had  great  difficulty  in  making  physicians 
understand  this  when  administering  anaesthetics  for 
me  for  the  extraction  of  teeth.    As  soon  as  the  patient 


General  Aiucsthctics  hi  Dentistry.  65 

was  rendered  helpless,  they  would  insist  on  me  begin- 
ning to  operate,  and  near  the  conclusion  of  the  opera- 
tion, they  would  say,  the  patient  struggling  and 
screaming,  "Go  ahead,  I  will  hold  her  hands  and  she 
won't  remember  it  when  she  comes  out."  This  is 
always  a  dangerous  procedure,  and  should  not  be 
sanctioned  by  the  dentist  or  allowed  in  the  dental 
office.  In  the  year  1906,  thirty  chloroform  deaths 
occurred  in  dental  chairs.  The  deaths  from  chloro- 
form in  dental  chairs  is  larger  than  the  percentage 
of  deaths  from  chloroform  in  the  office  of  the  physician, 
the  home  of  patients,  or  in  hospitals.  It  is  well  to 
bear  in  mind  that  some  patients  are  more  susceptible 
to  the  influence  of  anaesthetics  than  others.  Patients 
have  idiosyncrasies  in  regard  to  anaesthetics,  the 
same  as  with  other  drugs.  On  one  occasion,  a  pa- 
tient returned  to  my  office  with  a  pericemental  in- 
flammation, the  result  of  an  immediate  root  filling. 
My  iodine  and  creosote  bottle  accidentally  fell  from 
my  hand,  struck  the  iron  base  of  the  chair  and  broke. 
In  this  predicament  I  saturated  a  small  pellet  of  cotton 
with  chloroform  and  applied  it  to  the  gum  as  I  would 
have  applied  the  iodine  and  creosote  solution.  That 
amount  of  chloroform  was  in  this  case  sufficient 
to  produce  sleep  of  five  minutes  duration.  Having 
discovered  that  this  patient  was  so  susceptible  to 
chloroform,  on  several  subsequent  occasions,  with  the 
amount  of  chloroform  indicated,  I  prepared  a  number 
of  sensitive  cavities  for  fillings.  Had  it  been  necessary 
for  this  young  woman  to  take  chloroform  for  a  sur- 
gical operation,  being  so  susceptible  to  its  inlhience, 


66  General  Anirsthetics  in  Dentistry. 

the  quantity  usually  administered  in  the  beginning  by 
most  anaesthetists  might  have  produced  shock. 

It  is  important,  then,  in  the  very  beginning  of  anaes- 
thesia, with  all  irritating  anaesthetic  agents,  that  the 
narcotic-laden  vapor  should  be  administered  in  a  very 
dilute  form. 


General  Atiicsthetics  in  Dentistry.  67 


LECTURE  VI. 
Dental  Fatigue. 

We  have  said  that  shock  is  exhaustion  of  the  medul- 
lary centers,  the  result  of  irritating  the  sensory  (affer- 
ent) nerves ;  this  condition,  in  a  milder  degree,  con- 
stitutes fatigue.  Shock  is  dependent  upon  too  sudden, 
too  frequent,  too  painful,  too  forcible,  or  too  prolonged 
stimulation  of  the  afferent  nerves ;  the  same  is  true  of 
fatigue.  Dental  fatigue  and  dental  shock,  then,  differ 
only  in  degree.  Surgical  shock  is  a  dangerous  condi- 
tion and  the  general  surgeon  uses  every  precaution  to 
prevent  it.  Dental  fatigue  bordering  on  shock  must 
be  handled  with  the  greatest  of  care  by  the  dental 
surgeon  to  avert  shock. 

Every  dental  surgeon  has  and  every  dental  surgeon 
will  continue  to  have  his  quota  of  those  nervous,  high- 
strung  patients,  many  of  whom  suffer  with  pain  days, 
weeks,  and  even  months  before  they  can  nerve  them- 
selves to  the  ordeal  of  visiting  the  dentist.  Many  of 
them  will  tell  you  afterwards  that  they  got  as  far  as 
the  office  door  two  or  three  times  and  returned  home 
again.  I  recall  a  case  just  now  of  a  young  woman 
who  told  me  she  had  walked  to  my  office  on  three  suc- 
cessive days  a  distance  of  seven  miles,  through  the 
snow,   with    the    thermometer   twenty    degrees   below 


68  General  Ancesthetics  in  Dentistry. 

zero,  for  the  purpose  of  having  a  tooth  extracted.  Each 
time  the  tooth  stopped  aching  when  she  started  up 
the  steps,  and  not  till  the  third  trip  could  she  muster 
up  sufficient  courage  to  enter  the  office.  Such  patients 
are  to  be  pitied,  because  their  mental  suffering  far 
exceeds  the  severest  pain  that  could  possibly  be .  in- 
flicted. Recently  a  patient  said  to  me,  as  she  sat  in 
my  chair  ready  to  be  anaesthetized,  pale  and  trembling 
with  fear  (not  afraid  of  the  anaesthetic,  but  afraid  she 
would  be  hurt  in  spite  of  the  anaesthetic)  :  "Doctor, 
give  me  enough  please,  so  I  will  not  feel  the  pain ;  I 
had  rather  never  wake  up  than  to  have  you  hurt  me." 
An  anaesthetic  for  this  patient  was  her  only  salvation. 
It  would  have  been  dangerous  to  have  extracted  for 
this  patient  without  an  anaesthetic.  The  mind  has  a 
powerful  influence  over  the  body — positively,  construc- 
tively, by  enabling  it  to  overcome  obstacles ;  and  nega- 
tively, destructively,  by  acting  adversely  on  the  body. 
Such  patients  must  be  handled  with  the  greatest  of 
care.  At  the  first  sitting,  with  this  class  of  patients, 
if  only  an  examination  is  to  be  made  or  soft  decay  re- 
moved to  make  a  treatment  for  pulpitis,  the  face  be- 
comes pale,  respiration  impaired,  circulation  off,  the 
skin  moist,  and,  if  too  sudden,  too  painful,  or  too  pro- 
longed irritation  be  made,  the  centers  governing  res- 
piration and  circulation  are  exhausted,  fatigue  super- 
venes, and  shock  follows.  In  other  words,  too  great 
a  demand  on  nerve  centers  exhausts  them,  and  they  re- 
fuse to  act.  This  state  is  present  under  other  forms 
of  stimuli,  such  as  occur  in  the  painful  preparation  of 
cavities,   removing   pulps   of  teeth,   polishing   fillings, 


General  Aiicvsthetics  in  Dentistry.  69 

and  the  many  forms  of  nerve-racking  processes  which 
make  up  the  daily  operations  of  the  dental  surgeon. 
Often  the  class  of  patients  who  seem  to  be  bearing  the 
irritation  of  dental  operations  well  will  tell  you  to  go 
ahead  and  finish  what  you  are  doing,  but  all  at  once 
they  turn  pale,  perspiration  breaks  out  on  their  faces, 
and  the}',  in  spite  of  their  marvelous  force  of  will,  are 
exhausted.  This  is  what  1  mean  by  dental  fatigue.  In 
this  condition,  we  have  exhausted  the  reserves  of  the 
patient ;  we  have  brought  about  a  panic,  more  or  less 
serious. 

The  general  surgeon  employs  anaesthetics  to  pre- 
vent shock ;  the  dental  surgeon  should  employ  anaes- 
thetics to  prevent  fatigue  and  avert  shock.  A  small 
amount  of  nitrous  oxid,  ethyl  chloride,  somnoform,  or 
chloroform  will  soothe  the  fibrille  of  the  nerves  so  that 
they  will  not  send  so  frequent  or  so  strenuous  calls 
to  the  brain.  We  have  an  illustration  of  this  in  patients 
who  have  embraced  Christian  Science.  They  have 
practiced  that  form  of  nerve  inhibition  which  their  be- 
lief calls  for,  till  the  end  organs  no  longer  telegraph 
the  pain  sensations  to  the  upper  levels  of  the  brain, 
in  which  is  located  the  seat  of  consciousness.  Anaes- 
thetics accomplish  the  same  result  by  numbing  those 
in-carrying  nerves  of  sensation  so  that  they  do  not 
vibrate  to  [)eriphcral  stimuli.  The  Christian  Scientist 
has  learned  to  do  the  same  thing  that  the  auto-hypno- 
tist has  learned  to  do ;  overcome  or  prevent  pain  by 
nerve  inhibition.  I  resided  for  a  while  in  a  little  town 
in  eastern  Iowa.  Among  my  patients  was  a  Mrs.  P — . 
Mrs.  P — 's  teeth  were  very  sensitive.     All  I  could  ac- 


70  General  Ancesthetics  in  Dentistry. 

complish  or  hope  to  accomplish  for  Mrs.  P —  was  to 
secure  dryness  of  cavity  sufficient  to  retain  cement  for 
a  while.  No  attempt  at  cavity  preparation  was  ever 
made.  We  both  congratulated  ourselves  if  we  could 
succeed  in  protecting  the  teeth  from  the  irritants  of 
the  mouth.  Such  dentistry  afforded  only  temporary 
relief,  and  Mrs.  P —  was  my  most  constant  and  per- 
sistent patient.  I  moved  from  the  town  of  A —  to 
one  of  our  larger  cities,  C — .  One  day  three  years 
later,  a  patient  opened  the  office  door  and  walked  in ; 
it  was  Mrs.  P — .  That  feeling  of  fatigue  we  are  now 
discussing  came  over  me — that  dizzy,  fainting,  all- 
gone  feeling.  I  had  hoped  that  I  would  never  have 
to  operate  for  Mrs.  P —  again,  and  I  argued  with  my- 
self what  course  to  pursue  as  I  continued  with  my 
patient  before  greeting  her.  I  approached  her  and 
said:  "Good  morning,  what  can  I  do  for  you?"  She 
replied:  "You  do  not  remember  me,  do  you?"  I 
said:  "Yes,  I  do;  you  are  Mrs.  P—  of  A—."  "My 
teeth  have  all  gone  to  pieces  since  you  left  A — ,  and  I 
want  an  appointment,  for  we  are  living  here  now,  and 
I  can  come  at  any  time  and  as  often  as  you  wish  me." 
I  sat  down  by  her  side  and  said :  "Mrs.  P — ,  you 
know  that  your  teeth  are  so  sensitive  that  I  can  not 
operate  for  you  properly.  There  are  a  number  of  ex- 
cellent dentists  in  C —  and  I  prefer  that  you  have  your 
work  done  by  some  other  operator."  She  made  reply : 
"I  will  not  do  anything  of  the  kind.  I  am  a  Christian 
Scientist  now,  and  it  will  not  hurt  me  one  bit  to  have 
my  teeth  filled."  I  told  her  if  that  was  the  case  of 
course  it  would  not  hurt  her,  and  gave  her  an  appoint- 


General  Anccstlietics  in  Dentistry.  71 

ment.  Christian  Science  was  new  then,  and  this 
was  my  first  opportunity  to  operate  for  a  Christian 
Scientist. 

I  was  expecting  the  same  condition  of  afifairs  in  a 
modified  degree.  I  looked  for  some  improvement  in 
the  matter  of  self-control,  but  it  never  occurred  to  me 
that  she  would  prove  other  than  a  most  exasperating 
patient.  The  morning  of  the  appointment  arrived;  so 
did  Mrs.  P — .  All  of  her  anterior  teeth  were  carious 
gingivally,  the  cavities  extending  some  distance  under 
the  gum  margin.  There  were  approximal  and  occlusal 
cavities  also  in  the  anterior  and  posterior  teeth,  but  it 
occurred  to  me  that  these  cavities  along  the  gum  mar- 
gins would  aflford  a  good  test,  and,  if  I  succeeded  fairly 
well  here,  there  would  be  no  doubt  about  making  sat- 
isfactory fillings  in  all  of  her  teeth. 

I  started  to  make  a  cocaine  application  to  numb 
the  gum  in  order  to  more  comfortably  adjust  the  rub- 
ber  dam.  She  promptly  informed  me  that  she  did 
not  wish  any  drugs  used ;  it  was  not  necessary  in  her 
case.  I  adjusted  the  dam,  forced  the  gum  back  out  of 
the  way,  my  assistant  holding  it  l)y  means  of  a  liga- 
ture. I  not  only  ])ropared  one  cavity  that  morning, 
but  three,  and  tilled  them  with  gold,  and  Mrs.  P — 
never  so  much  as  wrinkled  her  forehead.  I  made 
fillings  wherever  they  were  indicated,. and  she  would 
leave  the  chair  after  two  or  three  hours'  sittings  with- 
out apparently  the  least  fatigue  or  exhaustion.  The 
first  superior  bicuspid  on  each  side  had  gradually 
crumbled  away  till  the  roots  were  completely  hidden. 
These  Mrs.  P —  wished  removed.    I  dissected  back  the 


72  General  Anccsthetics  in  Dentistry. 

gum  of  the  one  on  the  right  side,  located  the  edges 
of  the  root,  and  with  my  thinnest  blade  forceps,  pushed 
with  all  my  might ;  the  bone  spread  and  the  root 
popped  out.  When  I  showed  it  to  her  she  said :  'Is 
that  all  there  is  to  having  a  root  out."  I  pushed  up 
around  the  other  root  without  dissecting  the  gum,  and 
it  nipped  off  two  or  three  times,  but,  with  the  ex- 
ception of  her  face  getting  red  in  the  malar  region, 
there  was  nothing  to  show  that  she  was  the  least  dis- 
turbed physically  or  mentally  by  this  operation. 
"Great  God !"  I  said  to  myself,  "this  woman  is  the 
same  onh^  in  name  as  the  Mrs.  P —  I  used  to  work 
for  in  the  town  of  A — ." 

The  Christian  Science  movement  spread  rapidly  in 
that  community.  A  church  was  organized  and  they 
rented  a  room  across  the  hall  from  my  ofBce  in  which 
to  hold  their  meetings,  and  they  must  have  appointed 
me  their  official  dentist,  for  they  came  to  me  in  num- 
bers for  their  dentistry.  Mrs.  P —  became  a  healer, 
and  would  bring  me  patients  and  remain  with  them 
and  treat  them  as  I  operated,  and  another  healer,  a 
Mrs.  L — ,  would  do  the  same  thing.  The  eflfect  was 
marvelous.  Once  in  a  while,  some  of  my  old  patients 
would  return  for  work,  having  in  the  meantime  em- 
braced Christian  Science,  and  I  had  opportunities  to 
observe  the  effect  in  numerous  cases.  They  were  not 
all  like  Mrs.  P — .  Some  admitted  being  hurt;  some 
would  request  me  to  wait  a  moment,  now  and  then  ; 
but  all  of  them  maintained  a  marvelous  control  over 
themselves,  many  complaining  of  no  pain,  others  deny- 
ing that  they  experienced  pain. 


General  Aiucstlietics  in  Dentistry.  73 

Some  people,  by  constant  practice,  have  acquired 
the  habit  of  moving  their  scalp  backwards  and  for- 
wards ;  others  to  wriggle  their  ears  like  a  mule ;  while 
others  with  equal  celerity  have  learned  to  throw  their 
cerebral  hemispheres  out  of  gear,  to  exercise  the  power 
of  inhibition  and  shut  off  pain  from  certain  parts  of 
the  body,  much  the  same  as  the  electric  lights  in  one 
room  of  a  house  can  be  extinguished  at  pleasure,  by 
turning  a  switch,  while  the  lights  burn  brilliantly  in 
all  other  rooms  of  the  house. 

"You  will  find  recorded  in  Fox's  'Book  of  Martyrs' 
some  very  curious  statements  regarding  the  condition 
of  people  who  were  tortured  by  the  Inquisition.  It  is 
said  that  some  of  them  not  only  felt  no  pain,  but  felt 
positive  pleasure,  so  that  they  regretted  being  removed 
from  the  rack,  which  seemed  to  them  a  bed  of  roses." 
(Brunton.) 

We  can  not  instruct  our  patients  how  to  use  auto- 
hypnotism,  or  in  all  cases  overpower  them  with  sug- 
gestion, or  teach  them  the  art  of  inhibiting  pain  by 
throwing  their  cerebral  hemispheres  out  of  gear,  but  I 
will  instruct  you  how  to  obtain  the  same  results,  arti- 
fically,  by  the  use  of  nitrous  oxid,  ethyl  chloride,  som- 
noform  and  chloroform  vapor. 

Hypnotism  is  the  ideal  anresthetic,  the  anaesthetic 
par  excellent;  but  tlie  dental  profession  is  not  ready 
for  this  yet.  What  they  are  waiting  for  I  do  not  know. 
But  the  dentists  are  waiting,  holding  back,  I  suppose, 
just  as  they  have  delayed  availing  themselves  of  the 
use  of  general  anrcsthetics   for  dental  operations,  till 


74  General  Anccsthetics  in  Dentistry. 

the  general  public  demands  and  compels  them  to  adopt 
their  use. 

Some  twenty  years  ago.  Dr.  Chas,  Davis  of  Chi- 
cago, surgeon  in  charge  of  the  Temperance  Hospital, 
hypnotized  a  patient  for  me,  and,  in  this  h3^pnotic  state 
lasting  about  forty-five  minutes,  Dr.  W.  E.  Hodgin 
and  myself  prepared  and  filled  a  cavity  with  gold  in 
the  upper  left  central  incisor.  This  patient  did  not 
know  that  he  was  to  have  a  tooth  filled.  The  tooth 
was  a  difficult  one  over  which  to  adjust  the  rubber 
dam,  and  we  had  Dr.  Davis  make  the  suggestion,  "dry 
mouth,"  and  there  was  no  moisture  present,  and  cot- 
ton rolls  were  used  to  hold  the  lip  out  of  the  way. 
Further,  he  was  commanded  to  hold  his  mouth  open, 
and  this  he  did  throughout  the  entire  operation.  Dr. 
Davis  was  in  an  adjoining  room  and  did  not  return  till 
we  had  the  filling  completed.  The  doctor  aroused 
him  at  our  request  and  when  we  showed  him  the  filling 
he  was  very  much  surprised.  Suggestion  is  used  to- 
day, in  a  greater  or  less  degree,  by  all  physicians,  and 
hypnotic  clinics  have  been  established  in  which  all 
diseases  are  treated  under  hypnotism. 

The  psychic  causes  of  dental  fatigue  can  not  be 
eliminated  from  the  direct  or  physical  causes.  The 
psychic  causes  are  always  present  and  augment  the 
physical.  The  following  are  the  most  common  physi- 
cal causes;  inflicting  pain  too  suddenly — for  instance, 
thrusting  a  broach  into  a  pulp  which  is  supposed  to  be 
anaesthetized  with  cocaine  but  the  cocaine  has  not  been 
absorbed;  holding  the  rapidly  rotating  bur  too  long 
against  the   sensitive   dentine,   without   lifting  it   fre- 


General  Ancesthetics  in  Dentistry.  75 

quently  so  that  both  the  tooth  and  bur  may  have  an 
opportunity  to  cool ;  rapid  and  prolonged  grinding  with 
a  corundum-stone,  whether  shaping  a  tooth  for  a 
crown  or  completing  a  gold  filling  with  sandpaper 
strips  and  discs  when  the  patient's  vital  force  has  al- 
ready been  overtaxed ;  or  a  combination  of  two  or 
three  of  the  above  causes  at  the  same  sitting;  extrac- 
tion of  a  tooth  when  the  vital  forces  have  been  low- 
ered from  intense  suffering  and  loss  of  sleep ;  pro- 
longed efifort  to  remove  a  root  or  roots  after  the  tooth 
has  been  fractured ;  removing  too  many  teeth  at  a 
sitting  without  an  anaesthetic.  To  these  might  be 
added  too  freciuent  sittings  and  sittings  of  too  lengthy 
duration  even  though  the  operation  may  not  be  painful. 

Patients  exert  themselves  to  the  limit  of  endur- 
ance in  the  dental  chair.  If  we  stop  in  time,  shock  or 
collapse  is  avoided.  We  seldom  witness  an  exhibi- 
tion of  fatigue  in  the  dental  chair.  Patients  nerve 
themselves  for  the  ordeal,  store  their  energies  in  ad- 
vance, as  it  were,  as  we  charge  a  storage  battery.  It 
is  at  their  homes  after  leaving  the  office  that  the 
penalty  is  paid. 

The  remedy  in  all  these  cases  is  to  use  enough  of 
one  of  the  available  anaesthetics  to  relieve  dread  and 
fear.  The  easiest  people  to  persuade  to  take  an  ansees- 
thetic  are  those  that  suffer  most.  They  are  willing  to 
take  or  do  anything  to  avoid  pain  or  knowing  about 
what  is  going  on.  For  operations  other  than  extract- 
ing, the  analgesic  stage  is  usually  all  that  is  necessary. 
A  few  inhalations  of  chloroform,  somnoform  or  nitrous 
oxid  and  oxygen  usually  are  sufficient  to  render  oper- 


76  General  Anesthetics  in  Dentistry. 

ating  comfortable  for  both  the  patient  and  the  dentist. 

For  a  description  of  the  methods  employed  and  how- 
to  administer  nitrous  oxid,  nitrous  oxid  and  oxygen, 
ethyl  chloride,  somnoform,  and  chloroform  to  prevent 
dental  fatigue,  you  are  referred  to  the  lectures  on  these 
anaesthetic  agents,  individually. 

Case  I.  Miss  A — ,  a  school  teacher.  Extremely 
nervous  from  work  in  the  school-room,  presented  for 
removal  of  pulp  in  upper  right  second  bicuspid.  It 
was  simply  impossible  to  use  an  engine  on  this  tooth. 
Mouth-prop  adjusted,  nitrous  oxid  and  oxygen  was 
used,  and  pulp  removed  without  discomfort.  This 
patient  had  been  to  two  dentists  that  mornmg,  who 
failed  in  their  efforts  to  open  into  the  tooth  properly 
for  nerve  devitalization.  This  patient  left  the  office 
stimulated  and  not  exhausted,  as  on  all  former  occa- 
sions, when  leaving  the  dental  chair.  At  subsequent 
sittings  a  number  of  cavities  were  prepared  painlessly 
for  fillings,  under  nitrous  oxid  and  oxygen  analgesia. 

Case  II.  Mr.  B — ,  a  robust  man  about  forty  years 
of  age.  A  bridge  had  been  placed  in  the  mouth  sev- 
eral years  previously.  One  of  the  abutments,  an  upper 
molar,  had  not  been  devitalized.  The  pulp  had  died, 
infecting  the  tissues  above,  and  it  was  necessary  to  re- 
move the  bridge.  These  conditions  are  usually  as 
painful  as  the  dentist  is  ever  called  upon  to  treat.  The 
slightest  touch  of  the  bridge  was  simply  unendurable. 
Nitrous  oxid  and  oxygen  was  used  in  this  instance. 
The  crowns  were  slit,  the  bridge  removed,  and  the  pulp 
chamber  of  the  molar  entered  for  vent  and  drainage; 
time  required,  about  four  minutes. 


General  Aiucsthetics  in  Dentistry.  lit 

Case  III.  A  case  of  nerve  fatigue  and  collapse. 
Mrs.  J — ,  naturally  frail,  came  to  me  for  an  extraction, 
with  the  following  history.  She  had  in  her  mouth  a 
number  of  gold  fillings  beautifully  made,  the  Black 
cavity  preparation  l:)cing  followed  precisely.  Ihe 
operator  in  this  case  underestimated  the  vitality  of  his 
patient.  At  the  last  sitting,  she  informed  me,  she  col- 
lapsed in  the  chair,  was  unconscious  two  or  three 
hours,  and  for  months  was  confined  to  the  house  and 
could  walk  now  only  with  the  aid  of  a  cane.  With  a 
history  of  this  kind  and  the  patient  looking  more  dead 
than  alive,  an  extraction  becomes  an  important  matter. 
It  was  dangerous  to  extract  without  an  anaesthetic  ;  I 
would  not  assume  that  risk.  I  administered  somno- 
form  very  gently  with  the  Stark  inhaler  admitting 
mu-ch  air  and  got  along  nicely  without  after  trouble. 

Case  IV.  Nausea,  the  result  of  nerve  irritability. 
Patient,  a  healthy  young  farmer  unused  to  dental 
operations.  Operation,  preparation  of  a  cavity  in  a 
devitalized  lower  molar  and  insertion  of  a  gold  inlay. 
The  preparation  of  the  cavity  was  about  all  he  could 
stand,  and,  when  the  inlay  was  in  position,  slight 
grinding  with  a  corundum-stone  and  sandpaper  discs 
produced  nausea,  sick  stomach  and  fainting,  and  the 
operation  had  to  be  postponed.  He  remarked  that  he 
could  stand  pain,  but  the  grinding  sensation,  was  too 
much  for  him.  At  another  sitting  the  operation  was 
completed  under  nitrous  oxid  and  oxygen  analgesia 
without  nausea. 

Case  V.  Miss  C — ,  age  fourteen.  Havl  neglected 
her  teeth  on  account  of  dread  and  fear  of  the  dental 


78  General  Anesthetics  in  Dentistry. 

chair.  An  exposed  pulp  brought  her  to  the  office,  but 
her  courage  failed.  Upon  explaining  the  use  of  nitrous 
oxid  she  readily  consented  to  have  it  used,  and  her 
teeth  in  due  time  were  all  filled,  and  her  mouth  placed 
in  a  healthy  condition. 

Case  VI.  Little  boy,  about  eight  years  of  age.  I 
was  summoned  to  the  office  of  Dr.  M — ,  a  dentist,  to 
administer  somnoform  and  found  this  little  fellow 
waiting.  The  lower  right  central  incisor  was  in  a  state 
of  acute  alveolar  abscess.  I  administered  somnoform 
and  his  dentist,  with  a  new  bur  in  an  electric  engine, 
went  through,  the  disto-approximal  surface  into  the 
pulp  chamber  and  the  pus  oozed  out.  The  administra- 
tion of  the  anaesthetic  and  the  operation  did  not  con- 
sume more  than  sixty  seconds. 


General  Aiiocsthctics  in  Dentistry.  79 


LECTURE  VII. 
Elements  of  Success. 

Success  in  administering  anaesthetics  does  not  de- 
pend entirely  on  the  anaesthetic  employed  or  on  the 
manner  in  which  the  anaesthetic  is  administered. 
There  are  a  number  of  small  details  to  which  I  wish 
to  call  your  attention,  all  of  which  are  highly  impor- 
tant in  order  to  obtain  the  best  of  anaesthetic  results. 

The  anaesthetic  room  should  be  the  most  quiet 
room  in  the  ofifice.  It  should  also  be  the  most  private 
room.  The  forceps  should  at  all  times  be  kept  out 
of  the  sight  of  the  patient.  Adjoining  the  anaesthetic 
room  should  be  a  private  room,  the  rest  room  or  pre- 
paratory room.  In  this  room  should  be  a  dresser  with 
a  large  mirror,  a  sofa  or  lounge,  wash-basin  and  water, 
a  toilet,  if  possible,  and  a  large  supply  of  clean  towels. 
This  room  should  at  all  times  be  kept  neat  and  clean, 
being  especially  careful  that  no  blood-stained  napkins 
or  towels  be  in  sight. 

Usher  the  patient  first  from  the  reception  room  into 
the  anaesthetic  room,  if  you  are  so  situated  that  you 
can  have  a  room  for  this  exclusive  purpose.  In  this 
room  get  the  history  of  the  case,  make  your  diagnosis, 
decide  on  the  operation  and  know  for  a  certainty  ex- 
actly what  you  intend  to  do,  so  that  you  will  not  have 


80  General  Anccsthetics  in  Dentistry. 

to  make  another  examination  when  the  patient  takes 
the  chair  the  second  time. 

Your  lady  assistant  now  takes  the  patient  into  the 
preparatory  room.  The  assistant  understands  that, 
if  a  woman,  the  corset  must  be  removed,  no  matter 
what  objections  are  raised  by  the  patient.  The  collar 
should  be  removed  and  all  bands  loosened.  If  the 
patient  is  daintily  dressed  and  the  operation  is  one  in 
which  there  will  be  considerable  hemorrhage,  have  the 
assistant  take  ofif  the  waist  and  make  a  dressing-sack 
of  two  towels,  as  patients  frequently  put  their  fingers 
in  their  mouths,  and,  before  you  can  prevent  it,  will 
place  their  hands  on  their  gowns  and  soil  them,  a  situ- 
ation to  be  avoided.  If  the  bladder  has  not  been  recently 
emptied,  the  assistant  should  attend  to  this  before  the 
patient  takes  the  chair.  Right  here  is  the  test  of  your 
assistant.  If  she  understands  her  business,  she  can 
take  the  most  nervous  woman  and  talk  her  out  of  her 
nervousness.  Instruct  your  assistant  to  keep  up  a  run 
of  small  talk.  It  will  keep  the  mind  of  the  patient 
from  dwelling  on  the  operation.  You  can  take  it  for 
granted  that  usually  the  calmest  of  patients  are  fright- 
ened, terribly  frightened,  and  the  assistant  must  get 
them  over  this,  if  possible,  before  they  get  to  you. 
Have  her  tell  the  patient  there  is  nothing  to  dread ; 

say,  "Mrs. took  the  anresthetic  yesterday  and  she 

was  as  frightened  as  you  are,  and  she  had  a  delightful 
experience."  Keep  up  the  conversation,  don't  give  the 
patient  an  opportunity  to  tell  how  scared  she  is.  She 
will  get  worse  scared  in  the  telling.  Mention  a  num- 
ber of  pleasing  cases,  especially  some  one  of  their  ac- 


General  Aiucstlietics  in  Dentistry.  81 

quaintances,  if  possible — laugh  with  them ;  there  is 
nothing  like  a  laugh  to  make  one  feel  at  ease.  Jf  \our 
assistant  is  what,  in  the  language  of  the  street,  is  called 
a  "jollier,"  she  will  get  the  patient  in  a  good  frame  of 
mind  by  the  time  she  is  prepared  for  the  anaesthetic.  I 
have  known  patients  to  go  into  the  dressing-room 
white  with  fear,  and  step  out  into  the  operating-room 
quiet  and  tranquil  from  the  influence  exerted  by  the 
assistant. 

W' hile  the  patient  is  being  prepared  both  physically 
and  mentally  by  the  assistant,  there  are  some  things 
to  be  attended  to  in  the  operating-room.  These  things 
I  prefer  to  do  myself.  I  select  all  instruments  that  I 
anticipate  using  and  boil  them  thoroughly.  I  then 
arrange  them  on  a  table  in  the  order  in  which  I  expect 
to  use  them.  The  table  should  be  protected  by  a 
towel  and  another  towel  thrown  loosely  over  the  in- 
struments, to  conceal  them  from  the  patient.  Make 
ready  the  anaesthetic  appliance,  prepare  the  hands 
properly,  and  when  everything  is  in  readiuess  for  the 
patient,  and  not  until  then,  signal  the  assistant  to  place 
the  patient  in  the  chair.  Not  a  moment's  time  should 
now  be  lost  in  attending  to  anything  but  the  patient. 
As  soon  as  the  door  leading  from  the  rest  room  is 
opened  by  the  assistant,  begin  to  augment  what  she 
has  been  saying  about  the  anaesthetic  being  pleasant. 
If  you  are  not  accustomed  to  giving  anaesthetics,  you 
will  possibly  be  worse  scared  than  your  patient.  Don't 
show  it.  Act  as  if  giving  anaesthetics  was  the  pleasant- 
est  thing  in  life.  Try  to  make  your  patient  feel  that  it 
is  a  great  treat  to  take  an  anaesthetic.     Reassure  the 


82  General  Anccsthetics  in  Dentistry. 

patient  that  he  will  not  be  hurt — then  keep  your  word. 
Place  the  mouth-prop  in  position,  and  adjust  the  in- 
haler. Right  now  begins  your  worst  battle  with  that 
terrible  incubus  to  the  human  mind,  fear.  Be  gentle, 
kind  and  watchful,  but  above  all  things  be  masterful. 
Remember  that  your  enemy  to  a  successful  anaesthesia 
is  this  latent,  powerful  force  which  is  located  in  one  of 
the  deepest  levels  of  the  sub-conscious  mind.  Begin 
to  talk  away  their  fright.  Tell  them,  "You  are  now 
going  to  sleep  and  will  have  a  quiet  rest  and  wake  up 
when  I  call  you.  You  need  have  no  fear,  for  this  is 
sleep,  just  as  you  sleep  at  home  in  bed.  You  are  not 
afraid  when  you  go  to  sleep  at  home  and  you  are  not 
afraid  now.  1  am  watching  you  and  caring  for  you; 
nothing  can  harm  you.  Give  yourself  up  to  this  restful 
sleep.  You  are  now  getting  sleepy.  You  are  going  to 
sleep,"  Keep  up  this  talk  until  you  see  the  symptoms 
of  anaesthesia.  You  will  find  it  very  helpful  to  the  pa- 
tients as  they  are  passing  through  those  strange  doors 
of  artificial  sleep.  Suggestion  has  a  large  place  in  my 
anaesthetic  work,  and  I  heartily  recommend  you  to 
adopt  its  use.  With  such  suggestions  as  I  have  indi- 
cated, the  amount  of  anaesthetic  required  will  be  re- 
duced to  the  minimum. 

About  live  years  ago  a  young  man  came  from  a  dis- 
tant town  to  have  extracted  the  upper  third  molars.  I 
decided  to  use  somnoform.  I  had  just  procured  a 
Stark  inhaler  and  wished  to  try  this  very  beautiful 
appliance.  The  Stark  inhaler  is  so  arranged  that  the 
amount  of  anaesthetic  required  can  be  accurately  ob- 
tained.   You  can  admit  just  the  amount  of  air  needed 


General  Aiicesthetics  in  Dentistry.  83 

in  each  case,  or  you  can  exchulc  all  anaesthetic  and  give 
the  patient  a  few  inhalations  of  air  before  you  add  any 
anaesthetic.  I  allowed  this  patient  a  few  inhalations 
of  air  and  gave  him  the  verbal  suggestions  above 
indicated.  After  he  had  taken  about  six  inhalations 
of  air,  his  arm  dropped  to  his  side  and  he  to  all  ap- 
pearances was  anaesthetized,  yet  he  had  at  that  time 
breathed  only  air.  I  placed  the  inhaler  to  my  face 
to  see  if  I  could  be  mistaken.  No  somnoform  was  es- 
caping from  the  inhaler.  He  was  in  a  state  of  anaes- 
thesia without  inhaling  any  anaesthetic.  To  be  on  the 
safe  side,  as  I  had  promised  not  to  hurt  him,  I  gave  him 
two  inhalations  of  somnoform  with  about  half  air. 
I  extracted  the  teeth  and  waited  for  him  to  awaken. 
He  slept  for  a  few  minutes,  and  showed  no  signs  of 
waking  up,  so  I  called  to  him  and  told  him  to  wake 
up.  He  did  so  and  seemed  surprised  to  find  that  the 
teeth  were  out.  I  asked  him  if  I  had  hurt  him,  and 
he  said  that  he  did  not  feel  a  thing.  I  asked  him  wdiat 
it  was  like.  He  said:  "It  seemed  to  me  just  like  when 
they  hypnotized  me."  The  conversation  disclosed  the 
fact  that  he  had  been  used  as  a  subject  by  a  person 
who  was  studying  hypnotism,  and  had  thus  become 
very  susceptible  to  the  intluence  of  suggestion.  I 
would  not  advise  talking  hypnotism,  or  even  men- 
tioning hypnotism  to  a  patient,  but  used  in  this  way 
you  will  find  suggestion  a  very  helpful  influence  in 
anaesthetic  work. 

Having  mentioned  the  assistant,  let  me  say  a  word 
about  her  before  we  finish  this  subject.  A  thoroughly 
trained  assistant  is  three-fourths  of  the  battle.     The 


84  General  Ancusthctics  in  Dentistry. 

assistant  should  be  a  cool,  level-headed  woman,  physi- 
cally strong,  non-excitable,  quick  to  think,  and  a  keen 
observer.  She  should  know  anaesthetic  symptoms; 
understand  all  resuscitation  measures,  and  how  to  ap- 
ply them  ;  and  be  thoroughly  interested  in  the  work. 
If  you  can  not  teach  your  assistant  these  requirements; 
if  she  is  timid  and  can  not  learn  self-command,  you 
had  better  get  another  assistant,  or  get  a  trained  nurse 
to  stay  with  you  a  while  until  the  assistant  learns  how 
to  properly  assist  you.  You  can  teach  her  yourself 
if  you  take  pains  to  do  so,  out  of  office  hours,  or  when 
you  have  leisure.  Demonstrate  the  methods  of  arti- 
ficial respiration  on  her,  and  have  her  demonstrate 
them  on  you. 

While  you  are  administering  the  anaesthetic,  the 
assistant  should  stand  on  the  left  of  the  chair  and 
watch  the  patient  closely.  When  you  begin  to  operate, 
she  must  then  watch  the  patient  for  you,  and  notify 
you  at  once  of  the  slightest  abnormality.  In  addition 
to  this,  if  you  are  to  use  more  than  one  forcep,  she 
must  have  ready  the  other  instruments  in  the  order  in 
which  you  need  them.  She  must  see  that  the  lower  lip 
is  not  pinched ;  that  the  tongue  is  kept  out  of  the  way ; 
that  the  cheek  is  distended ;  that  the  mouth-prop  is 
removed  at  the  right  moment  in  multiple  extractions ; 
that  roots,  teeth  and  blood  do  not  go  down  the  throat. 
She  must  sponge  the  parts;  lean  the  patient  forward 
when  necessary ;  be  equal  to  any  emergency  that  may 
arise,  and  do  all  these  things  without  being  told.  All 
these  things  belong  to  the  province  of  the  assistant — 


General  Anccstlietics  in  Dentistry.  85 

yours  is  simply  to  take  charge  of  the  anaesthesia  and 
the  extraction. 

After  the  operation,  the  assistant  must  take  charge 
of  the  patient,  and  if  a  lady,  help  her  to  dress.  A 
cheerful  conversation  is  just  as  helpful  now,  as  before 
the  operation.  She  must  keep  patients  encouraged 
so  that  they  will  dress  and  get  out  into  the  fresh  air. 
Some  patients  have  the  idea  that  they  should  lie 
around  a  while.  This  must  be  avoided ;  is  not  neces- 
sary with  the  briefer  anaesthetics,  although  it  is  very 
important  after  chloroform  or  ether. 

After  the  patient  has  left,  the  assistant  can  then 
clean  all  the  instruments,  boil  them,  and  put  them 
away.  I  advise  boiling  after  use  so  that  if  an  instru- 
ment not  laid  out  should  be  needed  in  haste,  you  can 
feel  that  it  is  not  infected  with  mouth  bacteria. 

Just  in  proportion  as  your  assistant  does  these 
things  well  for  you,  will  you  be  successful,  provided 
that  you  are  cool,  non-excitable  and  a  good  extractor. 
The  poorer  the  assistant,  the  more  of  her  work  you 
have  to  do,  the  greater  will  be  the  chance  of  failure. 
With  such  an  assistant  as  I  have  described,  you  can 
give  your  whole  attention  to  the  extracting.  The  oper- 
ator who  does  not  know  for  a  certainty  if  the  patient 
has  loosened  her  clothing ;  who  relies  on  an  accom- 
panying friend  or  some  one  called  hastily  to  act  as  a 
witness,  in  lieu  of  an  assistant,  is  the  man  who  makes 
failures  in  the  use  of  anaesthetics. 

If  you  have  not,  and  can  not  procure  such  an  assist- 
ant as  I  have  described,  then  you  must  do  your  best 
to  allay  the  fears  of  your  patients  yourself.     You  can 


86 


General  Ancesthetics  in  Dentistry. 


do  this  before  the  patient  takes,  the  chair  for  examina- 
tion, while  you  are  examining  the  case,  and  before  you 
give  the  ansesthetic. 

An  anaesthetic  should  never  be  administered  to  a 
woman  in  a  dental  office  without  the  presence  of  an- 
other woman.  Scarcely  a  day  passes  that  some  woman 
does  not  say  to  my  assistant,  "I  am  so  glad  to  find  a 
lady  here."  That  very  fact  has  a  quieting  and  soothing 
effect  on  the  patient.  No  woman  wants  to  pass  into 
unconsciousness  in  the  presence  of  a  man  with  her 
clothing  unloosened.  Again,  especially  under  the  in- 
fluence of  nitrous  oxid,  patients  sometimes  have  amor- 
ous sensations,  and  a  woman  might  dream  that  im- 
proper liberties  were  taken  by  the  operator.  There  is  a 
case  on  record  where  the  presence  of  mother  and  sister 
failed  to  convince  a  girl  that  something  improper  had 
not  occurred.  The  following  case  came  under  my  ob- 
servation. One  Sunday  morning,  a  lady  came  to  my 
ofifice  to  have  a  tooth  extracted,  being  accompanied  by 
the  man  she  was  to  marry  that  evening.  I  adminis- 
tered nitrous  oxid  gas,  the  man  standing  on  the  left 
side  of  the  chair  holding  the  patient's  hand — no  one 
else  was  in  the  room.  While  under  the  influence  of 
the  anaesthetic,  the  patient  gave  evidence  of  under- 
going an  erotic  dream.  She  awoke  crying,  wringing 
her  hands  and  screaming  at  the  top  of  her  voice,  "Ford, 
you  have  ruined  me ;  Ford,  you  have  ruined  me," 
twentv  times  or  more.  The  situation  was  extremely 
embarrassing.  I  stepped  into  an  adjoining  room,  and 
from  the  conversation,  every  word  of  which  I  could 
hear,  it  was  evident  that  the  bridegroom  was  unable  to 


General  Ancesthetics  in  Dentistry.  87 

convince  her  that  she  had  not  been  wronged,  and  she 
left  the  office  in  that  state  of  mind.  In  "Turnbull  on 
Anaesthetics,"  you  will  find  a  number  of  interesting 
cases  that  he  has  collected  very  similar  to  the  one  I 
have  narrated. 

I  neglected  to  say  that  while  anaesthesia  is  being 
induced  perfect  quiet  must  be  maintained  in  the  room. 
No  talking  or  whispering  should  be  tolerated,  and  no 
words  spoken,  except  those  of  suggestion  to  the  pa- 
tient. This  should  be  continued  even  though  the  pa- 
tient, apparently,  is  asleep.  Some  patients  do  not  lose 
entirely  the  sense  of  hearing.  Again,  sounds  are  ex- 
aggerated under  the  influence  of  anaesthesia  and  an 
ordinary  tone  of  voice  may  sound  very  loud  and  ■  be 
disquieting  in  the  extreme.  For  this  reason  all  sug- 
gestions to  one  undergoing  anaesthesia  should  be  made 
in  a  quiet,  firm,  subdued  tone  of  voice.  I  speak  not 
a  word  to  anyone  in  the  room  while  inducing  anaes- 
thesia, except  to  the  patient.  All  communication  with 
the  assistant  is  conducted  by  means  of  signals.  This 
quietness  should  be  maintained  in  the  room  after  the 
operation,  while  the  patient  is  returning  to  conscious- 
ness. Conversation  is  prohibited.  If  patients  catch  a 
few  words  while  in  the  border-land  between  sleeping 
and  waking,  they  will  imagine  that  they  knew  all  about 
the  operation.  In  a  low  tone  of  voice,  say,  "You  are 
now  through  sleeping;  you  are  waking  up,  your  teeth 
have  been  removed,  and  there  has  been  no  pain." 
Language  appropriate  will  come  naturally  to  you  for 
each  case. 

As  soon   as   the   extracting  is  completed,   napkins 


88 


General  Anccsthetics  in  Dentistry. 


should  be  placed  in  the  mouth  to  absorb  the  blood. 
For  this  purpose,  my  assistant  uses  the  ordinary  anti- 
septic dental  napkins.  These  are  folded  so  as  to  be 
about  two  inches  in  length,  then  rolled  and  a  string 
tied  about  the  middle.  If  you  have  a  string  tied  to  the 
mouth-prop,  use  a  different-colored  string  for  the 
sponges.  If  only  two  or  three  teeth  are  extracted,  the 
moment  the  teeth  are  out  place  one  or  more  of  these 
napkins  rolls  under  or  over  the  sockets  of  the  extracted 
teeth,  just  as  you  would  insert  a  mouth-prop.  If 
nitrous  oxid  gas  or  somnoform  has  been  the  anaesthetic 
used,  leave  the  patient  undisturbed  until  he  is  suffi- 
ciently awake  to  rinse  the  mouth  with  water.  First 
remove  the  napkins,  then  the  mouth-prop.  Always 
follow  this  order,  as  you  might  be  deceived  as  to  the 
amount  of  relaxation  of  the  muscles  and  the  mouth 
might  close  tightly,  retaining  the  napkins  and  thus 
endanger  breathing  if  the  prop  was  removed  first. 

Never  lean  patients  forward  after  extracting  until 
they  are  sufficiently  aroused  to  free  their  mouths. 
There  are  two  reasons  for  this :  First,  before  con- 
sciousness has  returned,  patients  usually  pass  through 
a  dazed  and  confused  dreamy  stage,  and,  not  knowing 
where  they  are  or  what  has  occurred,  may  have  a 
bad  dream  at  being  suddenly  aroused.  Upon  seeing 
blood,  men  are  liable  to  think  that  they  have  been  in  a 
scrape  of  some  kind,  or  that  they  have  been  attacked, 
and  you  may  have  a  fight  on  your  hands.  If  you  try 
to  have  them  spit  before  they  are  sufficiently  awake, 
they  are  liable  to  spit  in  your  face,  or  on  the  walls  or 
the  floor,  or  anywhere.    Others,  being  frightened  when 


General  Anccsthctics  in  Dentistry.  89 

they  go  to  sleep  and  feeling  that  they  may  never  wake 
up,  imagine  when  you  disturb  them  that  you  are  try- 
ing to  resuscitate  them.  Second,  it  predisposes  to 
nausea.  I  believe  that  nearly  all  the  nausea  accom- 
panying nitrous  oxid  gas  or  somnoform,  the  clothing 
being  proi^erly  arranged,  is  the  result  of  raising  pa- 
tients up  too  soon  to  get  them  to  expectorate. 

In  larger  extraction  cases,  by  keeping  the  mouth- 
prop  in  place  the  blood  can  be  sponged  from  the  mouth 
as  in  any  other  surgical  operation.  When  used  in  this 
way,  do  not  fold  the  napkin,  but  use  it  as  a  sponge. 

The  modern  dental  chair  is  responsible  for  many 
anaesthetic  failures.  At  least,  that  has  been  my  experi- 
ence. I  have  tried  nearly  all  chairs  that  have  been  on 
the  market  the  past  thirty  years,  and,  while  the  old 
Archer  has  its  faults,  nevertheless  it  is  superior,  as 
an  anaesthetic  extracting-chair,  to  all  other  dental 
chairs,  when  nitrous  oxid,  ethyl  chloride  or  somnoform 
are  to  be  used.  The  old  wooden  Archer  chair  with  the 
detachable  foot-rest  is  the  chair  with  which  I  have 
been  most  successful.  This  is  a  surprising  statement, 
but  a  trial  is  convincing.  I  have  an  old  Archer  and 
also  one  of  the  most  modern  of  chairs  in  my  office. 
Occasionally,  to  hurry  matters  when  the  Archer  is  in 
use,  I  slip  a  patient  into  the  modern  chair,  to  make  an 
extraction,  and  nearly  always  promise  myself  that  I 
will  never  do  so  again.  The  difference  in  the  behavior 
of  the  patient  is  very  evident.  In  the  modern  chair,  the 
patient  places  his  feet  on  the  foot-rest  and  braces  him- 
self, pushing  backward.  This  pushing  with  the  feet 
causes  the  chest  to  rise,  interfering  with  the  iidialer; 


90  General  An(esthetics  in  Dentistry. 

pushing  harder,  the  head-rest  is  forced  to  one  side, 
or  the  head  slides  out  of  the  head-rest,  and  you  have  to 
substitute  your  left  arm  as  a  head-rest.  I  have  had 
patients  force  themselves  backwards  till  their  heads 
and  shoulders  w^ere  beyond  the  chair  and  have  ex- 
tracted in  that  position  many  times. 

In  the  modern  chair,  frequently,  when  just  about 
to  extract  or  while  extracting,  one  of  the  levers  holding 
the  head-rest  in  position  will  be  touched  accidentally 
by  the  arm  or  chest  or  by  the  assistant,  the  head  falls 
to  one  side,  one  of  the  most  annoying  things  to  hap- 
pen. I  have  had  broken  under  nitrous  oxid  anaesthesia 
the  foot-rest  of  two  S.  S.  W.  chairs,  and  the  back  of  a 
Morrison  chair,  from  force  exerted  by  the  patient, 
while  extracting  teeth. 

The  old  Archer  has  a  detached  foot-rest  on  rollers. 
When  the  patient  begins  to  push,  the  foot-rest  rolls 
forward,  and  the  legs  stand  out  straight  and  rigid  and 
the  patient  is  perfectly  helpless.  The  head-rest  is  se- 
cured by  a  thumb  screw  and  there  is  no  danger  of  its 
being  released.  The  objection  to  the  Archer  chair  is 
that  it  is  too  high  for  some  teeth  in  the  lower  jaw. 
This  objection  is  easily  remedied  by  standing  on  a 
foot-stool  or  box  made  for  that  purpose.  Next  in 
preference  is  the  Morrison  chair.  The  foot-rest  of 
the  Morrison  chair  is  so  constructed  that  the  part  on 
which  the  heels  rest  when  the  legs  are  extended,  the 
piece  against  which  the  patient  would  press  when 
bracing,  can  easily  be  detached  and  left  off.  The  Mor- 
rison then  becomes  an  excellent  chair  for  extracting 


General  AiucstJietics  in  Dentistry.  91 

teeth  under  nitrous  oxid,  ethyl  chloride  and  somno- 
form  anaesthesia. 

Not  only  does  the  head-rest  yield  b}-  the  force  ex- 
erted when  extracting  in  a  modern  dental  chair,  but  it 
is  no  unusual  occurrence  for  the  back  to  give  away 
when  the  patient  is  heavy  or  powerfully  built.  These 
accidents  of  the  chair  are  perplexing  in  the  extreme, 
and  are  responsible,  I  believe,  for  at  least  fifty  per  cent, 
of  the  failures  under  the  agents  mentioned  when  ad- 
ministered for  tooth  extraction. 

Tn  this  lecture  I  have  taken  into  consideration  a 
number  of  little  things,  the  things  that  are  either  over- 
looked by  most  operators  or  deemed  unimportant,  or 
too  trivial  to  ])ut  into  practice,  but  it  is  strict  attention 
to  these  small  things  and  following  out  such  details 
that  makes  my  anaesthetic  work  more  successful  than 
in  former  years. 


92  General  Anccsthetics  in  Dentistry. 


LECTURE  VIII. 
Relative  Safety  of  General  Anaesthetics. 

Nitrous  oxid  and  oxygen  is  considered  the  safest 
and  chloroform  the  most  dangerous  of  anaesthetic 
agents  in  general  use.  I  could  quote  pages  of  statistics 
to  show  the  percentage  of  deaths  that  occur  during 
anaesthesia,  all  by  recognized  authorities,  but  it  would 
be  a  loss  of  time  and  of  no  value  whatever.  There  is 
an  old  saying,  "You  can  find  what  you  look  for,"  and 
this  is  more  than  true  when  you  undertake  to  establish 
the  relative  safety  of  anaesthetics  by  statistics.  Figures 
may  not  lie,  but  you  can  juggle  them  to  suit  your  pur- 
pose, just  as  you  can  distort  the  truths  of  the  Bible 
if  you  so  wish.  The  following  illustration  is  not  log- 
ical or  true,  but  Scriptural :  "Judas  went  out  and 
hanged  himself" ;  "go  thou  and  do  likewise,"  "and 
whatsoever  thou  doest,  do  quickly." 

The  author  who  prints  statistics  to  prove  that  one 
death  occurs  in  every  thousand  administrations  of 
chloroform  may  be  set  down  as  one  partial  to  ether. 

Another  man  is  just  as  positive  that  the  average 
fatality  with  chloroform  is  not  more  than  one  in  four 
thousand.  Wood,  in  the  twelfth  edition  of  his  "Thera- 
peutics," says  the  average  mortality  is  one  death  in 
seven  hundred  thousand  administrations  of  N^O,  while 


General  Aiuvstlietics  in  Dentistry.  93 

a  New  York  writer  maintains  there  is  but  one  death  in 
one  million  administrations  of  NgO.  A  Chicago  man, 
a  somnoform  disciple,  has  recently  stated  that  he  is 
positive  there  is  one  death  in  every  twenty-five  thou- 
sand administrations  of  NoO.  Luke  says  there  have 
been  only  thirty-five  deaths,  all  told,  during  NoO  anaes- 
thesia. This  New  York  average  is  made  from  statis- 
tics of  NoO  administered  in  New  York  City,  covering 
a  period  of  ten  years,  and  looks  good  on  the  surface ; 
but  I  am  suspicious  that  this  writer  is  as  enthusiastic 
an  NoO  man  as  the  Chicagoan  is  a  somnoform  enthu- 
siast. According  to  the  New  York  statement,  it  is 
safer  "to  take"  NoO  than  to  cross  Broadway  or  Fifth 
Avenue ;  than  to  play  football  or  ride  on  the  elevated 
railway ;  to  attend  the  theater  or  go  slumming. 

Think  of  it — only  one  death  in  a  million  administra- 
tions of  NoO ! 

The  average  of  mortality  is  greater  among  men 
delivering  a  sermon  or  making  a  prayer,  eating  a  meal 
or  taking  an  afternoon  nap,  attending  a  banquet  or 
indulging  in  a  stroll. 

Even  with  a  showing  of  this  kind  for  N._,0,  almost 
beyond  belief,  the  somnoform  enthusiast  is  setting  up 
the  claim,  in  good  faith,  that  somnoform  is  the  safest 
of  all  ansesthetics.  It  almost  makes  one  feel  that  we 
would  be  safer  in  an  atmosphere  of  NoO  and  somno- 
form than  to  inhale  the  poisonous,  germ-bearing  air  of 
our  ofifices. 

I  will  take  the  liberty,  however,  to  quote  a  few 
statistics  to  make  clearer  my  position. 


94  General  Anccsthetics  in  Dentistry. 

Statistics  collected  by  Julliard : — 

Administrations. 

Chloroform    524,507     16  deaths— 1  in    3,258 

Ether .314,738     21  deaths— 1  in  14,987 

By  Ormsby : — 

Administrations. 

Chloroform    152,260     53  deaths— 1  in    2,873 

Ether 92,815       4  deaths— 1  in  23,204 

St.  Bartholomew's  Hospital : — 

Administrations. 

Chloroform    19,526     13  deaths— 1  in    1,502 

Ether  8,491       3  deaths— 1  in    2,830 

N^O  and  ether 12,941       1  death  —1  in  12,941 

By  Luke : — 

NoO   1  death  in  100,000  administrations 

Ethyl  chloride 1  death  in    12,000  administrations 

Ether 1  death  in    10,000  administrations 

A.  C.  E.  and  C.  E.  .  .  .  1  death  in      7,500  administrations 
Chloroform,  at  least  1  death  in      1,000  administrations 

Prinz,    from    recent    statistics,    covering    1,146,493 
narcoses,  ,crives  the  following: — 

Chloroform    1  death  in    3,500  administrations 

Ether 1  death  in  26,268  administrations 

C.  E.  Mixture 1  death  in    8,014  administrations 

The  German   Central  Society  of  Dentists  has  pre- 
jjared   a   series   of   records   of  the   number  of  general 


General  Anesthetics  in  Dentistry.  95 

narcoses  and  their  fatalities,  which  are  tabulated  from 
the  reports  of  its  members,  covering  a  period  of  four 
years  (1902-1905).  These  statistics  resulted  in  the  fol- 
lowing report : — • 

Chloroform    1  death  in    42,215  administrations 

Ethyl  Bromid 1  death  in  121,154  administrations 

Ethyl  Chloride.  .  .  .  Xo  death  in  70,630  administrations 
Nitrous  Oxid Xo  death  in      3,662  administrations 

Pastre  states  that  during  the  Crimean  War  only  1 
death  occurred  in  10,000  administrations  of  chloroform. 

Ihere  is  no  satisfaction  to  a  seeker  of  truth  in  such 
an  array  of  figures  as  quoted  above.  St.  Bartholo- 
mew's Hospital  statistics  show  that  there  is  an  average 
of  one  death  in  every  2,830  administrations  of  ether, 
while  Ormsby  shows  there  is  but  one  death  in  23,204 
administrations  of  ether.  Again,  Luke  says  there  is 
one  death,  at  least  in  every  1,000  administrations  of 
chloroform,  while  the  German  Central  Society  of  Den- 
tists maintain  there  is  but  one  mortality  in  every 
42,215  administrations  of  chloroform. 

If  the  estimate  is  correct  in  regard  to  one  death  in 
1.000,000  administrations  of  N„0,  no  dental  surgeon 
need  lay  awake  nights  worrying  over  mortalities.  If 
an  operator  should  administer  N^O  ten  times  per  day. 
including  Sundays  and  holidays,  and  took  no  vacations, 
he  would  be  entitled  to  only  one  mortality  in  274  years 
of  practice. 

If  we  should  take  all  the  statistics  that  have  been 
collected,  and  strike  an  averasre  showing  the  ratio  of 


96  General  Ancesthetics  in  Dentistry. 

deaths  to  the  number  of  times  a  given  aneesthetic  has 
been  administered,  it  would  have  no  bearing  on  the 
subject  whatever.  These  statistics  are  made  to  deter- 
mine the  percentage  of  deaths  during  anaesthesia,  and 
have  nothing  to  do  with  the  relative  safety  of  anaes- 
thetics. What  we  want  to  know  is  the  percentage  of 
deaths  caused  by  anaesthetics.  It  is  estimated  that 
105,000  people  die  every  day  of  the  year.  We  know 
that,  in  cases  of  injury,  where  men  are  so  horribly 
mangled  that  there  is  not  the  least  hope  of  recovery, 
for  humane  reasons  they  are  hurried  to  a  hospital, 
anaesthetized  and  operated  upon,  die  during  anaesthesia 
from  their  injuries,  and  these  cases  are  all  set  down  as 
deaths  under  ansesthetics.  Many  die  on  the  operating 
table  under  ansesthetics,  it  is  true,  but  die  from  disease, 
and  these  deaths  help  to  make  up  the  average.  Many 
die  at  the  close  of  a  long  operation  from  exhaustion ; 
many  more  die  from  shock,  as  the  result  of  operating 
too  soon  or  too  long ;  others  die  at  the  very  beginning 
of  the  operation  from  spasm  of  the  glottis,  the  anaes- 
thetic, improperly  administered ;  others  die  from  an 
overdose  of  anaesthetic,  others  from  collection  of  mu- 
cus, blood,  vomit,  etc.,  accumulating  in  the  pharynx, 
and  others  die  from  apoplexy,  heart  failure,  etc.,  just 
as  they  would  have  died  had  they  not  been  anaesthet- 
ized. When  we  take  into  consideration  that  medical 
men  and  dental  practitioners,  almost  all  of  them,  except 
a  few  who  are  fortunate  enough  to  become  internes, 
must  learn  to  administer  anaesthetics  themselves  after 
graduating,  it  is  surprising  that  there  are  not  many, 
many,  many  more  mortalities  during  anaesthesia.     It 


General  Anesthetics  in  Dentistry.  97 

is  said  that  "an  occulist  spoils  a  hatful  of  eyes  learning 
to  do  a  cataract  operation."  If  this  be  true,  Providence 
must  indeed  be  kind  to  young  men  in  their  early 
anaesthetic  career. 

The  medical  student  of  to-day  does  not  have  as 
good  an  opportunity  to  familiarize  himself  with  the 
administration  of  anaesthetics  as  students  of  twenty 
years  ago.  Formerly  anaesthetics  at  surgical  clinics 
were  administered  in  the  operating-room  in  the  pres- 
ence of  the  class ;  now  they  are  administered  in  an 
adjoining  room  and  wheeled  into  the  pit,  ready  for 
the  operation. 

Yes,  chloroform  is  the  most  dangerous  of  all  anaes- 
thetics, or  rather,  we  have  more  deaths  from  chloro- 
form, than  from  any  other  anaesthetic.  Chloroform  is 
not  so  much  to  blame,  however,  as  the  anaesthetist. 
When  we  understand  chloroform  better,  and  avail  our- 
selves of  sane  methods  of  administering  chloroform, 
the  death  rate  will  not  be  so  high. 

It  is  impossible  to  ascertain  the  percentage  of 
deaths  caused  by  anaesthetics.  I  am  satisfied  in  my 
own  mind  that  the  percentage  of  deaths  caused  by 
anaesthetics  is  very  small  as  compared  to  the  percent- 
age of  deaths  that  occur  during  anaesthesia.  When  the 
medical  schools  require  as  thorough  training  in  anaes- 
thetics as  they  do  in  anatomy,  histology,  pathology 
and  chemistry,  and  the  dental  schools  establish  an 
anaesthetic  clinic,  as  they  have  done  in  operative  and 
prosthetic  dentistry,  I  believe  that  in  ten  years  the 
mortality  under  anaesthetics  can  be  reduced  50  per  cent. 

The  safest  of  all  eeneral  anaesthetics  is  a  combina- 


98  General  Ancesthetics  in  Dentistry. 

tion  of  nitrous  oxid  and  oxygen.  Not  only  is  it  the 
safest,  but  likewise  the  most  pleasant  of  all  anaesthet- 
ics to  inhale,  and  the  patient  recovers  almost  the  in- 
stant the  inhaler  is  removed  from  the  face.  This 
anaesthetic  is  applicable  not  only  to  brief  and  unimpor- 
tant operations,  but  has  been  used  on  occasions  in  the 
gravest  of  conditions,  when  all  other  ansesthetics  were 
contra-indicated.  Not  many  months  ago  Dr.  Teter, 
of  Cleveland,  succeeded  in  keeping  a  patient  anaesthet- 
ized for  nearly  three  hours  with  nitrous  oxid  and  oxy- 
gen. On  this  occasion  the  patient  inhaled  600  gallons 
of  nitrous  oxid,  and,  if  I  remember  correctly,  80  gal- 
lons of  oxygen.  While  this  combination  is  the  safest 
of  all  anaesthetics,  it  is  the  most  difficult  of  all  to 
administer. 

The  next  in  order  of  safety  is  nitrous  oxid,  and  next 
in  order  of  difficult  administration  is  nitrous  oxid.  It 
is  unfortunate  that  the  most  pleasant  anaesthetics  to 
take,  and  without  doubt  the  least  dangerous,  should 
be  the  most  difficult  to  administer.  Dr.  Laird  W. 
Nevius,  of  Minneapolis,  has  administered  NjO  nearly 
100,000  times  without  an  accident.  Could  these  anaes- 
thetics be  handled  as  easily  as  ether  or  chloroform, 
without  special  apparatus  and  clumsy  cylinders,  there 
would  be  no  need  of  the  more  dangerous  anaesthetics 
now  in  common  use.  It  was  a  triumph  worth  record- 
ing when  the  manufacturers  learned  to  liquify  nitrous 
oxid  and  place  it  in  cylinders  for  our  convenience.  If 
the  manufacturer  would  go  one  step  further,  and  do 
for  us  what  has  been  done  with  ethyl  chloride  and 
somnoform,  in  the  way  of  putting  it  in  a  convenient 


General  Aiursthetics  in  Dentistry.  99 

form  for  use,  it  would  be  a  benediction  second  to  the 
discovery  of  anaesthesia. 

Somnoform,  the  most  beautiful  of  all  anaesthetics 
in  its  action,  the  easiest  of  all  anaesthetics  to  adminis- 
ter, the  most  reliable  of  all  anaesthetics  for  brief  opera- 
tions, so  far  as  the  record  of  deaths  during  anaesthesia 
shows,  as  safe  as  nitrous  oxid.  Properly  adminis- 
tered, sonmoform  has  no  rival ;  for  efficiency,  it  stands 
alone  in  a  class  of  its  own.  You  can  come  nearer  get- 
ting a  perfect  result  every  time  you  make  an  adminis- 
tration, with  somnoform,  than  you  can  with  any  other 
anaesthetic  with  which  I  am  acquainted.  In  the  hands 
of  the  skilful,  intelligent  anaesthetist,  the  careful, 
painstaking  anaesthetist,  as  safe  as  the  safest  anaes- 
thetic, but  in  the  hands  of  the  careless,  ignorant,  reck- 
less anaesthetist  accidents  may  arise  from  its  improper 
administration. 

While  there  have  been  but  few  deaths  from  nitrous 
oxid  and  oxygen,  and  only  about  thirty-five  deaths 
during  or  as  the  result  of  nitrous  oxid,  in  sixty-eight 
years  of  use,  and  the  percentage  of  deaths  from  somno- 
form no  greater  than  that  of  nitrous  oxid,  yet  there  is 
this  to  be  said  about  somnoform:  you  might  push  it 
far  enough  to  result  in  an  accident  without  the  patient 
showing  much  evidence  that  anything  was  wrong ;  • 
while  with  nitrous  oxid  the  patient's,  appearance  and 
actions  would  be  such  as  to  alarm  and  frighten  the 
anaesthetist,  thus  giving  ample  warning,  as  a  danger- 
ous condition  was  approached.  You  could  tie  a  patient 
down,  and  smother  him  to  death  with  any  of  the  anaes- 
thetics,  if   vou   held   tlicni   over   his   nose   and   mouth 


100  General  Ancesthetics  in  Dentistry. 

long  enough,  excluding  all  air,  but  you  must  remember 
always,  it  is  not  what  an  anaesthetic  can  do,  ad  libitum, 
but  what  it  does  when  properly  and  skilfully  admin- 
istered. 

Next  in  order  of  safety  may  be  placed  ether.  Ether 
may  be  employed  for  brief  operations,  and  is  usually 
selected  for  prolonged  surgical  operations.  The  fact 
that  the  percentage  of  deaths  during  or  as  the  result 
of  ether  administration  has  been  materially  lessened 
with  improved  methods,  shows  conclusively  that  the 
larger  percentage  of  deaths  in  the  past  are  chargeable 
to  the  anaesthetist  rather  than  the  anaesthetic. 

A  prominent  surgeon  told  me  recently  that  since 
the  drop  method  of  administering  ether  had  come  into 
such  general  use  he  did  not  think  there  was  more  than 
one  ether  death  in  20,000  administrations.  Hewitt, 
from  a  careful  analysis  of  the  statistics  collected  by 
him,  argues  that  ether  is  about  seven  times  as  safe  as 
chloroform.  Ether  is  certainly  gaining  in  favor  over 
chloroform,  and  its  administration  is  no  longer  consid- 
ered a  dangerous  procedure.  Indeed,  in  the  hands  of 
a  competent  anaesthetist,  the  risk  of  ether  anaesthetic 
accidents  is  infinitesimal. 

Ethyl  chloride  is  very  popular  just  now  in  England 
and  on  the  Continent,  and  in  our  Eastern  cities.  As  to 
the  matter  of  safety,  this  anaesthetic  may  be  classed 
between  ether  and  chloroform.  It  is  employed  mostly 
for  the  induction  of  brief  anaesthesia,  and  frequently  as 
preliminary  to  ether.  Luke  gives  this  anaesthetic  a 
death  rate  of  one  in  twelve  thousand.  It  is  a  peculiar 
circumstance  that  so  many  deaths  should  occur  under 


General  Anccsthetics  m  Dentistry.  101 

ethyl  chloride,  while  somnoform,  which  is  eighty-three 
per  cent,  ethyl  chloride,  is  amazingly  safe.  I  think  in 
time  improved  methods  of  administering  ethyl  chloride 
will  greatly  reduce  the  death  rate. 

Chloroform  is  the  most  dangerous  of  all  anaesthet- 
ics, or  rather  the  percentage  of  deaths  under  chloro- 
form is  higher  than  that  of  any  anaesthetic  in  general 
use.  Chloroform,  however,  is  not  so  much  to  blame  as 
the  careless,  reckless,  almost  criminal,  manner  in  which 
it  is  administered.  A  more  intimate  knowledge  of 
chloroform,  and  a  better  understanding  of  its  physio- 
logical action,  along  with  improved  methods  of  admin- 
istration, will  increase  its  efificiency  and  decrease  the 
percentage  of  mortality. 

The  fact  that  some  anaesthetists  confine  themselves 
to  the  use  of  chloroform  exclusively  and  have  never 
witnessed  a  death  during  or  as  the  result  of  chloro- 
form anaesthesia,  argues  that  the  manner  in  which 
chloroform  is  administered  has  much  to  do  with  the 
success  or  failure  attained.  All  or  nearly  all  deaths 
that  occur  during  the  first  two  or  three  minutes  of 
chloroform  administration,  are  caused  from  fright,  or 
because  the  vapor  is  too  heavily  laden  with  the  anaes- 
thetic. Those  deaths  that  occur  as  the  result  of  shock, 
because  the  patient  is  not  sufficiently  anaesthetized,  are 
not  chargeable  to  chloroform.  Deaths  happen  under 
chloroform  very  suddenly  at  times,  the  pulse  giving  no 
preliminary  warning,  the  breathing  normal,  and  the 
patient  evidently  doing  well,  but  these  conditions  arise 
when  a  large  nerve  is  severed,  or  the  vital  organs 
handled    or    squeezed,    or    the    vagus    is    dragged    or 


102  General  An<zsthetics  in  Dentistry. 

stretched.  Hewitt  says :  "It  is  by  no  means  improb- 
able that  some  of  the  sudden  deaths  which  have  oc- 
curred under  anaesthetics  and  which  have  been  ascribed 
to  their  action  have  in  reality  arisen  from  cardiac  or 
pulmonary  embolism." 

It  must  be  remembered  that  in  addition  to  the 
causes  already  enumerated  that  produce  or  lead  up  to 
death  during  chloroform  induction  or  narcosis,  that 
chloroform,  per  se,  is  a  protoplasmic  poison,  and,  when 
a  sufficient  amount  has  accumulated  in  the  system, 
shock  may  arise  from  this  cause.  This  is  not  probable 
if  the  anaesthetist  will  constantly  keep  in  mind  that 
two  per  cent,  of  chloroform  is  sufficient  to  anaesthetize 
a  patient  and  one  per  cent,  is  all  that  is  required  to 
maintain  anaesthesia. 

As  unusual  care  must  be  exercised  in  administering 
chloroform,  and  as  most  physicians  are  more  familiar 
with  ether,  it  is  safer  to  employ  ether  for  all  cases  of 
extracting  teeth,  in  which  the  choice  lies  between  ether 
and  chloroform,  whenever  the  extracting  is  to  be  done 
in  a  dental  office. 

It  is  utterly  impossible  to  ascertain  the  percentage 
of  deaths  caused  by  anaesthetics.  The  best  we  can  do  is 
to  determine  the  number  of  deaths  that  occur  during 
anaesthesia.  Hundreds  of  deaths  are  ascribed  to  anaes- 
thetics, and  they  go  down  in  history  as  anaesthetic 
deaths,  when  the  anaesthetic  was  in  no  way  responsible. 
It  is  customary  for  some  physicians,  and  even  some 
hospitals,  to  ascribe  all  or  nearly  all  deaths  that  follow 
a  surgical  operation,  to  shock,  the  result  of  the  anaes- 
thetic.    No  matter  how  skilful  a  surgeon  may  be,  and 


General  Aucrsthefics  in  Dentistry.  103 

no  matter  what  may  be  the  real  cause  of  death  during 
anaesthesia  or  following  the  operation,  it  sounds  better 
to  the  family  of  the  deceased,  to  the  public  and  even 
to  the  surgeon  himself,  to  have  it  said  that  the  patient 
died  from  the  efifects  of  the  anaesthetic  than  that  he 
died  as  the  result  of  the  operation.  When  the  report 
is  spread  abroad  that  the  patient  died  from  the  effect 
of  the  anaesthetic,  the  case  is  closed.  When  it  is  whis- 
pered around  that  the  patient  died  from  the  operation, 
the  inference  is  that  the  surgeon  was  at  fault,  and  some 
one  has  blundered.  This  is  a  factor  that  is  to  be  taken 
into  consideration  when  a  death  occurs  during  an 
operation,  and  for  this  reason  we  will  never  be  able  to 
ascertain  accurately  the  number  of  deaths  that  are 
caused  by  the  anaesthetic  agent  per  se. 


104  General  Ancesthetics  in  Dentistry. 


LECTURE  IX. 
Nitrous  Oxid  Gas. 

Priestly  discovered  nitrous  oxid  gas,  Sir  Humphry- 
Davy  recognized  its  pain-relieving  qualities,  Horace 
Wells  discovered  its  anaesthetic  properties,  Colton  in- 
duced with  it  the  first  surgical  anaesthesia,  Riggs  per- 
formed the  first  operation,  the  extraction  of  an  upper 
third  molar  tooth  from  the  mouth  of  Wells,  and  Dr.  E. 
Andrews,  of  Chicago,  was  the  first  to  add  oxygen  to 
prolong  nitrous  oxid  anaesthesia. 

A  long  and  bitter  controversy  arose  as  to  whom 
was  due  the  credit  of  discovering  surgical  anaesthesia. 
Dr.  Burton  Lee  Thorpe,  in  his  biographical  sketch  en- 
titled "Horace  Wells,  Dentist,  Humanity's  Greatest 
Benefactor,  the  Discoverer  of  Surgical  Anaesthesia,"  in 
the  Dental  Brief,  for  July  and  August,  '06,  has  settled 
that  question  forever.  Dr.  Laird  W.  Nevius,  who  as 
a  young  man  practiced  with  Colton  in  New  York  City, 
in  a  volume  of  his  own  furnishes  us  with  many  inter- 
esting incidents  relative  to  the  early  history  of  all  the 
general  anaesthetics. 

In  the  year  1844,  a  Dr.  Colton  delivered  a  popular 
course  of  lectures  on  chemistry,  and  in  the  month  of 
December  happened  to  be  in  Hartford,  Conn.  He  con- 
ducted his  lecture  course  on  the  same  plan  as  men  have 


General  Anccsthetics  in  Dentistry.  105 

been  doing  of  late  years  on  hypnotism.  On  this  par- 
ticular occasion  nitrous  oxid  was  discussed  and  mem- 
bers of  the  audience  invited  to  the  stage  to  inhale 
nitrous  oxid  to  the  point  of  stimulation  to  amuse  those 
present.  Dr.  Horace  Wells  was  present  and  with 
others  took  his  place  on  the  platform.  He  inhaled  the 
"laughing  gas,"  as  it  was  then  called,  and  was  pleased 
with  the  sensation  produced. 

The  exciting  incident  to  him  at  the  evening's  en- 
tertainment was  when  Mr.  Samuel  A.  Cooley,  a  well- 
known  Hartford  man,  gave  a  lively  exhibition  of  the 
effects  of  the  gas  by  running  and  jumping  about  and 
falling,  striking  his  legs  against  the  wooden  settees, 
and  acting  apparently  perfectly  unconscious  of  possible 
danger.  After  the  effects  of  the  gas  had  passed  off. 
Dr.  Wells  asked  him  if  he  was  hurt,  and  he  replied 
that  he  did  not  know  it  at  the  time,  but  on  looking  at 
his  legs,  found  them  bleeding  from  injuries  received. 
Dr.  Wells,  turning  to  Mr.  David  Clark,  said:  "I  be- 
lieve a  man,  taking  gas,  could  have  a  tooth  extracted, 
or  a  limb  amputated,  and  not  feel  the  pain."     (Thorpe.) 

The  events  of  the  evening  so  impressed  Dr.  Wells 
that,  after  the  lecture,  he  went  to  the  home  of  Dr. 
Riggs,  of  pyorrhoea  alveolaris  fame,  to  discuss  the 
matter  with  him,  and  decided  that  he  would  inhale  the 
gas  on  the  morrow  if  Dr.  Riggs  would  operate  for 
him.  Next  morning,  at  the  office  of  Dr.  Riggs,  Colton 
administered  the  gas.  Wells  inhaled  it,  and  in  the  pres- 
ence of  Cooley,  Dr.  Riggs  extracted  an  upper  third 
molar.  Wells  exclaiming  after  remaining  unconscious 


106  General  Ancesthetics  in  Dentistry. 

a  few  seconds,  "I  did  not  feel  so  much  as  the  prick  of  a 
pin — a  new  era  in  tooth  pulling."     (Thorpe.) 

Twenty-five  years  after  Priestly  discovered  nitrous 
oxid  gas,  Sir  Humphry  Davy  suggested  that  it  might 
be  used  for  relieving  pain ;  but  forty-four  years  again 
elapsed  before  Wells  demonstrated  this  prophecy,  Dec. 
11th,  1844. 

"On  that  day  modern  anaesthesia  was  given  to  the 
world,  and  nitrous  oxid  gas  has  proved  to  be  a  blessing 
to  suffering  humanity  and  the  forerunner  of  all  other 
anaesthetics."     (Thorpe.) 

I  know  not  what  name  was  used  in  the  beginning 
to  describe  this  state  or  condition  we  now  call  "anaes- 
thesia." Two  years  later,  when  Morton,  another  den- 
tist, discovered  the  anaesthetic  properties  of  ether.  Dr. 
Oliver  Wendell  Holmes  wrote  him:  "Everybody 
wants  to  have  a  hand  in  the  great  discovery.  All  I  will 
do  is  to  give  you  a  hint  or  two  as  to  names  or  the  name 
to  be  applied  to  the  state  produced  and  to  the  agent. 
The  state  should,  I  think,  be  called  'anaesthesia.'  The 
adjective  will  be  'anaesthetic'  Thus  we  might  say, 
'the  state  of  anaesthesia,  or  the  anaesthetic  state.' " 
(Thorpe.) 

Nitrous  oxid  is  a  colorless,  transparent  gas  of 
sweetish  odor  and  taste,  non-irritating  to  the  tissues, 
and  not  unpleasant  to  inhale.  Nitrous  oxid  gas  is  not 
a  poison  in  itself  nor  does  it  form  poisonous  combina- 
tions or  deleterious  chemical  relations  with  the  con- 
stituents of  the  blood.  It  does  not  decompose  during 
its  passage  through  the  circulatory  system,  the  body 
temperature  not  being  sufficient  to  cause  disintegration. 


General  Anaesthetics  in  Dentistry.  107 

Many  theories  have  been  advanced  to  explain  the 
anaesthetic  action  of  nitrous  oxid.  At  first  it  was 
thought  that  hyper-oxygenation  of  the  blood,  the  result 
of  the  oxygen  and  nitrogen  separating  and  the  oxygen 
being  absorbed  by  tlie  blood,  was  the  cause,  resulting 
in  an  internal  asphyxia.  Later,  Duret  and  Blanche 
maintained  that  the  anaesthetic  effect  of  nitrous  oxid 
depended  on  an  insufficient  amount  of  oxygen  rather 
than  a  superabundance.  It  was  these  views  that  gave 
rise  to  the  asphyxial  theory ;  namely,  that  one  who  had 
inhaled  a  sufficient  amount  of  nitrous  oxid  to  produce 
anaesthesia  was  asphyxiated  and  not  anaesthetized. 
Andrews,  of  Chicago,  about  this  time,  was  adding  oxy- 
gen to  nitrous  oxid  to  prolong  the  anaesthetic  effect, 
producing  by  the  use  of  this  mixture  a  non-asphyxial 
anaesthesia.  A  non-asphyxial  anaesthesia  can  also  be 
obtained  by  the  addition  of  air  to  nitrous  oxid  gas. 
Anaesthesia  can  be  maintained  for  hours  at  a  time  by 
the  addition  of  either  oxygen  or  air,  without  the  least 
asphyxia,  proving  conclusively  that  nitrous  oxid  pos- 
sesses anaesthetic  properties  of  its  own. 

"The  initial  sensations  under  nitrous  oxid  arc  of  an 
agreeable  and  stimulating  character,  almost  identical 
with  those  of  ether  and  chloroform ;  and,  when  non- 
asphyxial  and  deep  nitrous  oxid  anaesthesia  is  estab- 
lished, this  anaesthesia  is  similar,  in  its  main  features, 
to  that  i)roduced  by  other  anaesthetics.  Were  nitrous 
oxid  anaesthesia  the  result  of  simple  oxygen  depriva- 
tion, we  should  not  expect  the  initial  sensations  pro- 
duced by  the  inhalation  to  be  of  an  exhilarating  char- 
acter.    Nitrous  oxid  has,  in  fact,  quite  as  great  a  claim 


The  Improved  Teter  Apparatus  No.  1,  with  vapor  warmer  and 
stand,  attached  to  2,500-gallon  Teter  nitrous  oxid  cylinder,  and 
1,000-gallon  Teter  oxygen  cylinder,  pressure  gauges,  etc.  This 
appliance  has  an  attachment  by  the  use  of  which  etiicr  may  be 
administered  with  nitrous  oxid  and  oxygen  in  any  proportion  from 
one  to  twenty  per  cent. 


General  AncvstJictics  in  Dentist rx. 


109 


as  chloroform  to  be  considered  a  general  ancesthetic." 
(Hewitt.) 

A  mixture  of  nitrous  oxid  and  oxygen  can  be  in- 
haled indefinitely,  but  this  is  not  true  of  nitrous  oxid 


THE  CLARK  XEW  MODEL  OXYGEN  AND  XITROUS  OXID 
GAS  APPARATUS. 

alone.  Nitrous  oxid  does  not  support  animal  or  vege- 
table life,  and  it  is  not  safe  to  administer  it  even  as  long 
as  one  minute  if  all  air  be  excluded.  "In  the  case  of 
man,  the  average  inhalation  period  is  56  seconds;  at 


110 


General  Aiiccsthctics  in  Dentistry. 


the  end  of  that  time,  fresh  oxygen  must  be  admitted 
or  permanent  asphyxia  will  result."     (Hewitt.) 

Claude  Martin,  of  Lyons,  administered  a  mixture  of 
nitrous  oxid  and  oxygen  to  a  dog  for  three  consecutive 
days,  and  the  dog  was  none  the  worse.  Only  fifteen 
per  cent,  of  oxygen  was  used. 


THE   CLAEK   MIXING   DEVICE. 

METHOD    OF    CHANGING    THE    MIXTURE. 

When  the  pointer  is  at  nitrous  oxid,  the  opening  from  the 
nitrous  oxid  bag  is  wide  open.  When  the  pointer  readies  the 
marking,  the  first  mark  indicates  that  the  valve  is  now  at  the 
opening  leading  to  the  oxygen  outlet  and  moving  the  pointer  any 
further  in  the  direction  of  the  oxygen  side  will  begin  to  mix 
oxygen  with  nitrous  oxid. 

The  further  the  valve  is  turned  in  the  direction  of  the 
oxygen  the  more  oxygen  is  allowed  to  escajse,  until  the  point 
"mix"  is  reached.  At  this  point,  if  the  bags  contain  the  same 
amount  of  gas,  equal  amounts  of  nitrous  oxid  and  oxygen  are 
going  to  the  inhaler.  After  the  jjointer  passes  "mix"  a  larger 
percentage  of  oxygen  than  nitrous  oxid  is  being  given,  and  this 
increases  until  the  markings  on  the  oxygen  side  is  reached,  when 
the  nitrous  oxid  is  shut  off  entirely  and  oxygen  only  is  then  pass- 
ing through  the  outlet. 

The  operation  of  the  valve  is  so  simple  that  the  one  using 
it  can  make  no  mistake.  If  more  oxygen  is  required,  or  more 
nitrous  oxid,  it  is  simply  a  question  of  moving  the  large  handle 
one  way  or  the  other,  until  the  mixture  best  suited  to  the  patient 
is  obtained.  The  appliance  as  shown  Iiere  is  equipped  with  100- 
gallon  cylinders,  but  it  can  be  used  in  connection  with  the  large 
cylinders  with  gauges  and  pressure   indicators   if  desired. 


General  /liucstlictics  in  Dentistry.  Ill 

When  animals  arc  killed  by  pure  nitrous  oxid  gas, 
an  examination  shows  the  right  cavity  of  the  heart  to 
be  full  of  blood  and  the  left  cavity  empty ;  the  same 
condition  is  found  when  animals  die  of  asphyxia.  Post- 
mortem examinations  of  patients  who  have  died  under 
nitrous  oxid,  as  reported  by  Hewitt,  when  asphyxia 
has  been  assigned  as  the  cause,  have  also  disclosed  the 
fact  that  the  right  cavity  of  the  heart  was  full  and  the 
left  empty.  Johnson  believes  that  however  asphyxia  is 
induced — whether  by  nitrous  oxid,  by  nitrogen  or  by 
paralyzing  respiration  by  curare — the  same  effects 
follow. 

It  is  not  difficult  to  understand,  as  nitrous  oxid  pro- 
duces asphyxia  if  air  is  excluded,  and  the  post-mortem 
examination  of  an  animal  that  has  died  from  nitrous 
oxid  shows  the  same  patiiologic  condition  of  the  heart 
as  is  found  when  death  results  from  asphyxia,  that 
nitrous  oxid  should  have  been  classed  as  an  asphyxiat- 
ing agent  rather  than  an  anaesthetic  agent.  It  is  gen- 
erally conceded  that  nitrous  oxid  is  a  heart  stimulant 
and  causes  increased  blood  pressure. 

Kemp  thinks  that  contraction  of  the  renal  vessels 
takes  place,  resulting  in  a  decreased  urinary  secretion  ; 
also  that  albuminaria  is  nroduced  in  a  slight  degree  in 
complete  narcosis. 

An  overdose  of  nitrous  oxid  produces  death  in 
nearly  all  cases  from  asphyxiation,  the  heart  in  some 
cases  continuing  to  beat  for  a  period  of  several  min- 
utes after  breathing  ceases.  Hewitt  thinks  the  imme- 
diate cause  of  respiratory  arrest  is  usually  muscular 
spasm. 


112 


General  .iiucsthctics  in  Dentistry. 


The  McKesson  Apparatus  with  two  small  tanks  as  they  may 
be  attached,  and  showing  the  automatic  bag-filling  valves  con- 
nected by  small  rubber  tubings,  which  may  be  attached  to  a  gas 
plant,  large  cylinders  or,  with  a  special  yoke  and  pressure-reducing 
valve,  to  one  or  two  small  tanks  in  another  room. 

The  technic  of  administering  gas  and  oxygen  with  the  McKes- 
son Apparatus  is  easily  acquired,  because  the  instrument  works 
automatically.  Without  attention,  it  keeps  the  supply  bags  prop- 
erly filled  with  their  respective  gases,  produces  an  absolutely 
uniform  mixture,  permits  the  patient  to  rebreathe  only  a  certain 
desired  portion  of  each  exhalation,  prevents  contamination  of  the 
oxygen  and  nitrous  oxid  supply  bags  with  breathed  gases  and 


General  /incesthetics  in  Dentistry.  113 

Nitrous  oxid  gas  is  made  by  heating  ammonia 
nitrate.  The  gas  thus  generated  passes  through  two 
or  three  wash  bottles  to  absorb  any  impurities  that 
may  be  present,  and  is  collected  in  a  large  tank  or 
gasometer. 

In  an  early  day  it  was  customary  for  dentists  to 
manufacture  their  own  nitrous  oxid,  but  at  the  present 
time  only  a  small  nunil)er  of  the  extracting  specialists 
and  those  using  gas  in  large  quantities  make  their  own 
gas.  There  are  obstacles  to  be  met  and  overcome  in 
the  manufacture  of  nitrous  oxid,  such  as  inability  to 
obtain  the  same  grade  of  ammonia  nitrate  each  time, 
and  regulating  the  requisite  degree  of  heat  to  obtain 
uniform  results ;  for  these  reasons  and  other  annoy- 
ances, even  the  extracting  specialists  are  turning  to 
the  wholesale  manufacturers  for  their  supplies  of  this 
anaesthetic  agent. 

Farraday,  in  1823,  succeeded  in  liquefying  nitrous 
oxid  gas.  The  manufacturers  have  taken  advantage 
of  this  discovery  and  have  learned  how  to  condense 
nitrous  oxid.  This  is  done  under  immense  pressure 
at  a  low  temperature,  and,  in  order  to  confine  the  gas 
in  this  state,  heavy  steel   cylinders  are  used.     Cylin- 


wiuins  tli(>  gns  l)eforo  entoring;  tlie  air  passages.  The  anaesthetist 
hohls  tiie  mask  to  the  face,  sets  the  oxygen  and  nitrous  oxid  per- 
centage vahes  for  wliatever  mixture  of  these  gases  lie  desires, 
determines  the  volume  of  tidal  respiration  and  sets  the  adjust;ible 
rebreathing  bag  for  whatever  jjortion  he  wants  the  patient  to 
rebreathe,  if  any.  He  tlsen  watches  his  i)atient  for  the  sj-mptoms 
which  will  indicate  whether  the  mixture  is  correct  or  not  and 
makes  such  corrections  as  are  necessarj'.  A  beginner  who  is 
familiar  M'ith  the  properties  of  this  anaesthetic  and  who  is  thor- 
oughly acquainted  with  other  antesthetics,  will  often  give  a  buc- 
cessful  gas-oxygen  ansestb^sia  of  an  hour  for  ma^or  surgerj^  on 
til?  first  trial, 


114 


General  Anesthetics  in  Dentistry. 


AN    X-EAY    VIEW    OF    THE    M'KESSON    APPARATUS 

PROPEE,  SHOWING  THE  CONSTRUCTION 

IN   DETAIL. 

1.  Automatic  self-filling  bags. 

2.  Square  gas  channels  with  valves  which  actually  represent 
the  percentage  of  each  gas  used. 

3.  Both  NoO  and  O  check  valves  are  mounted  on  the  same 
shaft  so  that  the  oxygen  valve  cannot  ' '  stick, ' '  but  opens  with 
each  inhalation,  resulting  in  a  smooth  anassthesia. 

4.  A  separate,  adjustable,  graduated  bag  for  rebreathing, 
which  measures  the  tidal  respiration  in  cubic  centimeters  (a 
source  of  valuable  information)  and  permits  of  instantaneous 
adjustment  for  any  amount  of  rebreathing  to  be  performed  auto- 
matically and  uniformly.  If  desired  the  gas  from  the  "Bronchia 
tree"  only,  amounting  to  140  c.  c,  which  contains  no  CO2,  may 
be  stored  at  each  exhalation,  to  be  rebreathed  at  the  next  inhala- 
tion, thus  saving  73  gallons  of  gas  per  hour  and  in  no  way  inter- 
fering with  anaesthesia  or  the  safety  of  the  patient. 

5.  Moving  parts  are  always  yiaibli?  through  the  plate  glass; 


General  Anccstlietics  in  Dentistry.  115 

ders  are  now  being  made  that  contain  as  small  an 
amount  as  twenty-five  gallons  to  those  that  contain 
as  much  as  thirty-two  gallons  of  nitrous  oxid.  As 
nitrous  oxid  gas  does  not  deteriorate  with  age,  the 
larger  cylinders  are  more  convenient  for  dentists  re- 
mote from  a  dental  depot  who  have  to  pay  transporta- 
tion charges.  One  feels  far  more  comfortable  with  the 
larger  cylinders  when  administering  nitrous  oxid  for  a 
prolonged  surgical  anaesthesia,  and  even  in  dental  prac- 
tice it  is  assuring  to  feel  that  there  is  sufficient  gas  for 
the  operation  without  the  annoyance  of  changing 
cylinders.     Taking  into  consideration  the  transporta- 


6.  A  very  light  face  piece  with  an  expiratory  valve  so 
guarded  that  the  inhaled  breath  cannot  be  blown  toward  the 
operative  field. 

7.  A  practical  ether  cup,  which  may  be  used  in  a  variety  of 
ways:  (A)  For  the  administration  of  ether  in  conjunction  with 
NjO  and  O,  thus  securing  relaxation  in  the  most  refractory 
patient.  (B)  For  the  administration  of  ether  with  air  and  pure 
oxygen.  (C)  For  the  administration  of  ether  with  rebreathing 
and  other  combinations. 

8.  Compactness.  The  apparatus  may  be  carried  in  its  case 
and  sufficient  gas  in  the  other  case  for  a  three  to  four-hour 
administration   at   the   patient's   home. 

Eebreathing  should  be  done  not  primarily  to  save  gas,  but  to 
prevent  "over-ventilation"  of  the  blood  frv)m  rapid  respiration, 
which  is  a  factor  in  the  causation  of  shock.  The  patient  ordinarily 
should  not  take  more  fresh  gas  than  he  would  breathe  of  air, 
normally  (7,000  to  8,000  c.  c.  per  minute).  If  he  breathes  30 
times  per  minute  of  500  c.  c.  or  1,500  c.  c.  per  minute,  the 
rebreathing  bag  should  be  set  for  one-half  that  volume  or  250 
c.  c,  so  that  at  each  inhalation  he  will  rebreathe  250  c.  c.  of  the 
previous  exhalation  and  but  250  c.  c.  of  fresh  gases,  thus  restoring 
the  normal  ventilation  of  the  blood  and  preventing  excessive  loss 
of  COo,  and  the  tendency  to  develop  shock.  With  a  ventilation 
below  8,000  c.  c.  rebroattiing  should   not   be  i)orniitted. 

With  this  apparatus  the  only  anaesthetic  which  approaches 
absolute  safety  may  be  easily,  smoothly  and  scientifically  admin- 
istered for  any  operation.  With  a  nasal  inhaler,  the  dentist  or 
[jhysician  may  obtain  a  state  of  analgesia  for  prolonged  periods 
without  assistance  while  intra  oral  or  other  work  is  being  done. 
Or  a  profound  anapsthesia  for  removal  of  teeth,  tonsils,  adenoids, 
^tc,  may  be  continued  as  long  as  necessary, 


116 


General  Ancvsthetics  in  Dentistry. 


tion  charges  and  the  loss  in  each  cylinder  when  the 
gas  does  not  come  out  even,  the  larger  C3dinders  are 
far  more  economical  than  the  smaller. 

In  the  earlier  manufacture  of  cylinders,  annoyance 
and  inconvenience  was  caused  from  imperfect  valves- 


THE   OHIO   :\IONOVALVE. 


For  the  administration  of  nitrous  oxid  and  oxygen.  Chloro- 
form and  ether  can  also  be  used  with  this  appliance  in  combina- 
tion with  nitrous  oxid  and  oxygen.  A  device  for  warming  these 
gases  can  be  easily  attached.  This  appliance,  as  shown  in  the  cut, 
is  equipped  with  100-gallon  nitrous  oxid  cylinders  and  40-gallon 
oxygen  cylinders.  It  can  be  connected  up  with  the  larger  cylin- 
ders containing  as  much  as  3,200  gallons  of  nitrous  oxid  and  the 
amount  of  oxygen  corresponding.  The  appliance  is  manipulate^ 
by  the  operation  of  a  single  valve. 


General  Aiiccsthetics  in  Dentistry. 


117 


These  valves  would  permit  the  gas  to  escape  and 
sometimes  only  one  or  two  administrations  of  nitrous 
oxid  could  be  made  from  a  one  hundred-gallon  cylin- 
der. It  is  embarrassing,  when  you  only  need  two  or 
three  more  inhalations  to  complete  an  anaesthesia,  to 


NO.    1    POETABLE   STAND,   WITH    STYLE    F    CYLINDERS. 


Cylinders  hold  350  fi;allons  oxygon  and  1,280  gallons  nitrous 
oxid.  Stand  can  be  omitted  and  wall  clamps  supplied  when 
desired. 

The  regulators  automatically  reduce  the  gas  pressure,  caus- 
ing an  even  flow  which  can  be  perfectly  controlled. 

These  cylinders  are  manufactured  by  the  Ohio  Chemical  Com- 
pany and  used  with  their  Ohio  Monovalve  Appliance, 


118  General  Ancesthetics  in  Dentistry. 

find  the  cylinder  exhausted,  which  is  supposed  to  be 
two-thirds  fulL  Four  gallons  of  nitrous  oxid  weigh 
one  ounce.  It  requires  five  and  one-third  gallons  of 
oxygen  to  weigh  an  ounce. 

One  hundred  gallons  of  nitrous  oxid  should  weigh 
just  about  25  ounces.  Each  cylinder  has  marked  on  it 
or  on  a  tag  attached  to  it  the  weight  of  the  cylinder 
and  the  weight  of  the  gas.  It  is  a  good  plan  to  weigh 
the  cylinder  when  you  unbox  it  and  ascertain  if  there 
has  been  a  leakage  and  about  how  much. 


WARMING  DEVICE,  INCLUDING  ETHER  OR  CHLOROFORM 
ATTACHMENT    FOR   OHIO   MONOVALVE. 

Gas  passes  tlirough  a  radiator  in  a  receptacle  filled  with  water. 
The  water  is  heated  by  electricity  and  temperature  controlled  by 
a  rheostat.  In  the  absence  of  electricity  the  hot  water  can  be 
renewed  during  long  operations.  Ether  or  chloroform  are  regu- 
lated to  drop  as  frequently  as  desired  on  a  |^ot  surfacgj  causing 
perfect  expansion  of  the  liquid  tO  gas, 


General  Anesthetics  in  Dentistry.  119 

If  an  administration  has  not  been  made  for  some 
time  and  you  are  in  doubt  as  to  the  amount  of  nitrous 
oxid  that  should  be  in  the  cylinder,  it  is  better  to  weigh 
the  cylinder  than  take  the  risk  of  having  the  gas  a  little 
short  of  enough  to  induce  the  desired  anaesthesia. 

Just  recently  the  manufacturers  have  equipped  their 
large  cylinders  with  pressure  regulators,  enabling  one 
to  tell  the  number  of  gallons  of  these  gases  that 
remain  in  the  cylinders  at  any  time. 

The  more  modern  appliances  are  provided  with  two 
cr  four  cylinders,  so  arranged  that  you  can  switch 
from  an  empty  to  a  full  cylinder ;  but  even  this  involves 
a  loss  of  time  and  division  of  attention  when  the  oper- 
ator should  not  be  interrupted. 

The  matter  of  appliances  is  an  important  one. 
There  are  many  from  which  to  select,  each  having  its 
advantages. 

The  addition  of  oxygen  to  nitrous  oxid  for  the  pur- 
pose of  prolonging  anaesthesia  has  resulted  in  a  modifi- 
cation of  the  older  appliances  to  adjust  themselves  to 
the  new  condition.  Nitrous  oxid  without  the  addition 
of  oxygen  can  be  used  in  all  the  appliances  to  which 
I  shall  call  attention  or  describe. 


130  General  Ancrsthetics  in  Dentistry. 


LECTURE  X. 
Nitrous  Oxid  Administration. 

For  the  sake  of  convenience,  we  will  discuss  this 
subject  in  the  following  order: 
First:    Nitrous  oxid  pure,  without  air. 
Second :    Nitrous  oxid  with  an  admixture  of  air. 
Third :    Nitrous  oxid  and  oxygen. 

There  is  only  one  anaesthetic  more  difficult  to  ad- 
minister than  nitrous  oxid ;  namely,  nitrous  oxid  and 
oxygen.  Too  much  apparatus  is  necessary  in  the  ad- 
ministration of  nitrous  oxid  to  make  it  popular,  and, 
for  this  reason  it  will  never  be  universally  adopted  by 
dentists  as  ether  and  chloroform  have  been  by  physi- 
cians. When  the  physician  operates,  he  simply  oper- 
ates and  has  no  care  of  either  the  patient  or  the  anaes- 
thetic ;  but  when  the  dentist  has  occasion  to  administer 
nitrous  oxid  he  usually  performs  a  three-fold  service; 
namely,  plays  the  role  of  anaesthetist,  assumes  the  care 
of  the  patient,  and,  in  addition  to  these,  performs  the 
operation.  In  other  words,  he  assumes  the  duties  of 
anaesthetist,  nurse  and  surgeon.  No  surgeon  would 
undertake  to  administer  his  own  anaesthetic,  care  for 
the  patient  and  jjerform  an  operation,  except  in  the 
extremest  emergency ;' yet  the  dentist  assumes  such  a 
responsibility,  and  when  failures  result  blames  nitrous 


General  Anccstlietics  in  Dentistry.  121 

oxid,  never  for  a  moment  taking  into  consideration 
that  he  has  attempted  to  accomplish  too  much. 

It  would  be  a  simple  matter  to  administer  ether  and 
extract  a  number  of  teeth  without  an  assistant,  as  com- 
pared to  administering  nitrous  oxid  alone  and  extract- 
ing a  number  of  teeth.  With  ether  you  could  anaesthe- 
tize the  patient  sufficiently  deep  to  complete  the  opera- 
tion before  beginning  to  operate ;  while,  with  pure  ni- 
trous oxid,  you  have  only  about  ninety  seconds  in 
which  to  anaesthetize  and  operate,  and  there  is  too 
much  for  any  man  to  do  in  so  brief  a  time. 

Nitrous  oxid  in  itself  is  an  excellent  anaesthetic; 
it  can  do  all  that  has  been  claimed  for  it,  and  those  who 
have  failed  to  successfully  administer  this  anaesthetic 
are  at  fault,  and  not  the  anaesthetic.  This  is  why  in  a 
previous  lecture  1  laid  so  much  stress  on  the  import- 
ance of  a  well-trained  assistant.  Indeed,  some  of  our 
most  successful  extracting  specialists  extract  only,  the 
assistant  assuming  the  entire  anaesthetic  responsibility. 
Let  us  assume,  then,  in  all  that  I  shall  say  in  regard  to 
administering  nitrous  oxid  gas,  whether  in  the  pure 
state  or  in  combination  with  admixtures  of  air  or  oxy- 
gen, that  a  good  assistant  is  as  essential  to  success  as 
an  appropriate  appliance,  as  a  good  anaesthetist  or  as  a 
skilful  extractor. 

If  ^•ou  have  not  read  the  lecture- on  "I^lemenls  on 
Success,"  in  regard  to  tlie  i)rui)cr  preparation  of  the 
patient,  both  mentally  and  physically,  preliminary  to 
administering  an  anresthotic,  I  recommend  that  you  do 
so  before  perusing  this  lecture. 

The  patient  having  been  made  ready,  as  previously 


122  General  Anesthetics  in  Dentistry. 

explained,  with  a  good  assistant  at  the  left  of  the  chair, 
the  patient  properly  and  comfortably  arranged  in  the 
chair,  only  the  mouth-prop  is  lacking;  that  adjusted, 
we  are  ready  to  consider  the  administration  of  nitrous 
oxid. 

Never  administer  nitrous  oxid  without  first  insert- 
ing a  mouth-prop.  Insert  the  mouth-prop  the  last  thing 
before  adjusting  the  inhaler.  It  is  never  safe  to  ad- 
minister nitrous  oxid  without  a  mouth-prop,  and  I  con- 
sider one  criminally  negligent  to  do  so.  There  are  a 
number  of  reasons  why  a  mouth-prop  shoidd  be  used ; 
the  one  we  are  interested  in  just  now  is  to  hold  the 
jaws  apart  in  order  to  facilitate  speedy  operating. 
Many  dental  surgeons  fail  just  here.  Under  nitrous 
oxid  anaesthesia,  the  masticatory  muscles  usually  con- 
tract, sometimes  violently.  Having  satisfied  yourself 
upon  removing  the  inhaler  that  the  patient  is  suffi- 
ciently anaesthetized  to  begin  operating,  if  a  prop  has 
not  been  used,  the  mouth  will  be  found  closed,  and 
sometimes  the  teeth  forcibly  held  together,  and  so 
much  time  is  consumed  in  opening  the  mouth,  if  it  can 
be  opened  at  all,  that  the  tooth  is  fractured  in  the 
hurry,  or  the  wrong  tooth  extracted,  or  the  patient  is 
hurt,  or  awakes  and  nothing  has  been  accomplished. 

Hewitt  gives  the  average  induction  period  of  nitrous 
oxid  gas  without  air  as  fifty-six  seconds,  and  the  aver- 
age available  anaesthesia  about  thirty  seconds,  so  there 
is  no  time  for  forcing  the  mouth  open,  and  it  is  highly 
important  that  the  month-prop  l)e  not  neglected. 

Let  me  say  just  here,  make  it  a  rule  never  to  hurt 
your  patient.     The  object  in  taking  nitrous  oxid  gas 


General  Aiucsthetics  in  Dentistry.  123 

is  to  avoid  the  pain  of  the  operation.  If  you  lose  too 
much  time  in  getting  started,  you  better  not  operate 
at  all  than  to  have  the  patient  hurt.  The  patient  will 
complain  to  all  his  neighbors  that  he  knew  everything 
that  was  done,  and  was  never  so  badly  hurt  in  his  life, 
and  advise  everybody  he  meets  for  weeks  against 
taking  nitrous  oxid.  Exercise  the  greatest  of  care,  in 
the  beginning,  in  the  selection  of  suitable  subjects. 
The  operation  itself  should  be  of  the  simplest  nature. 
Some  one  may  present  with  one  easy  tooth  to  ex- 
tract, or  two  or  three  loose  pyorrhoea  teeth.  With  such 
a  case,  there  is  no  anxiety  about  the  operation,  but 
your  entire  attention  can  be  given  to  administering 
the  anaesthetic,  studying  the  patient  and  learning  an- 
aesthetic symptoms.  It  is  unreasonable  on  your  part 
to  expect  to  obtain  perfect  results  from  the  very  first 
administration,  and  to  start  in  as  an  accomplished 
anaesthetist.  You  do  not  expect  to  do  this  in  other  de- 
partments of  dentistry  when  you  take  up  something 
new  with  which  you  are  not  familiar. 

It  is  an  excellent  plan  to  reserve  the  anaesthetic  for 
such  cases  forty,  fifty,  sixty  times  or  more,  gaining 
confidence  each  time,  and  later  undertake  more  difficult 
cases.  If  a  patient  presents  "with  a  mouthful  of  teeth" 
to  be  extracted,  make  no  promise  in  advance  as  to  the 
number  you  will  remove  under  one  administration  of 
nitrous  oxid  gas.  If  you  should  promise  ten  and  suc- 
ceed in  extracting  but  three,  you  make  a  sad  failure. 
Say  this:  "I  will  extract  as  many  as  I  possibly  can,  and 
will  not  hurt  you,"  and  be  sure  to  cease  extracting  be- 
fore they  feel  pain.     You  might  say  that  "much  de- 


124  General  Anesthetics  in  Dentistry. 

pends  upon  the  breathing,"  as  explained,  and  that 
"some  patients  are  more  deeply  anaesthetized  than 
others."  If  you  succeed  in  removing  three  or  four 
teeth,  you  are  safe ;  if  you  should  succeed  in  extracting 
eight  or  ten  teeth,  your  reputation  is  made  with  that 
patient.  Whatever  the  number,  be  sure  to  stop  before 
the  patient  feels  pain.  Better  not  extract  at  all  if  from 
nervousness  the  patient  does  not  take  the  anaesthetic 
well ;  but  have  him  return  another  day.  It  will  con- 
demn any  anaesthetic  to  operate  too  soon  or  too  long 
and  the  patient  feel  the  pain. 

In  regard  to  extracting  under  nitrous  oxid,  let  me 
say  it  is  a  very  different  proposition  from  extracting 
without  an  anaesthetic.  It  is  something  that  has  to  be 
learned,  no  matter  how  skilful  an  extractor  you  may  be. 
Without  an  anaesthetic,  the  patient  keeps  his  tongue 
out  of  the  way,  and,  in  a  degree,  the  cheeks,  and  the 
mouth  opens  wider  if  you  wish  it,  and  the  head  turns 
to  one  side  or  the  other  on  command;  but,  under 
nitrous  oxid  gas,  you  must  be  careful  not  to  wound 
the  tongue  or  cheeks,  must  accommodate  yourself  to 
the  space  obtained  by  the  mouth-prop,  and  operate 
speedily. 

To  return  again  to  the  administration  of  nitrous 
oxid  gas,  measures  must  be  taken  to  exclude  all  air. 
Adjust  the  inhaler  to  the  face  and  satisfy  yourself  that 
it  fits  accurately.  The  pneumatic  cushion  or  rim  should 
not  be  blown  up  too  tightly,  but  about  half  full  of  air ; 
then  it  can  more  accurately  be  made  to  conform  to  the 
features  than  when  more  tense  or  rigid.  If  the  patient 
wears  a  heavy  mustache  or  beard,  especially  the  beard, 


General  Anccsthctics  in  Dentistry.  125 

it  is  an  excellent  plan  to  dampen  some  surgeon's  gauze 
and  place  three  or  four  layers  around  the  rim,  then 
press  this  tightly  against  the  beard  with  the  inhaler. 
Have  the  assistant  release  the  gas  and  allow  it  to  pass 
into  the  rubber  bag  until  it  is  almost  full.  Shut  off  the 
gas  for  a  moment,  open  the  exit  valve  and  the  gas  in 
the  bag  will  force  out  of  the  tube  running  from  the  bag 
to  the  inhaler  the  air  it  contains.  It  is  very  important 
that  the  valves  should  work  accurately  and  sensitively. 
Adjust  the  face-piece  carefully  this  time  and  see  that 
no  air  can  gain  admittance  under  the  pneumatic  rim, 
the  valves  having  been  tested  previously  to  ascertain 
if  they  are  in  perfect  working  order.  Instruct  the  pa- 
tient to  breathe  deeply  and  regularly.  I  prefer  in  the 
beginning  that  they  take  three  or  four  inhalations  of 
air  through  the  inhaler,  the  gas  being  shut  off;  then 
gradually  admit  the  nitrous  oxid  gas.  From  this  time 
on,  exclude  all  air.  The  assistant  should  now  keep  the 
gas  bag  nearly  full,  and,  when  the  patient  is  sufficient- 
ly anaesthetized,  be  sure  to  turn  off  tightly  at  the 
cylinder. 

Judging  from  my  own  experience,  eight  gallons  is 
the  average  amount  of  nitrous  oxid  gas  necessary  to  in- 
duce anaesthesia,  when  all  air  is  excluded;  Hewitt  says 
six.  In  some  cases,  I  have  found  two  or  three  gallons 
sufficient ;  in  others,  fifteen  or  twenty  gallons.  Frail 
patients,  children  and  an^emics  are  very  susceptible  to 
nitrous  oxid  gas ;  the  plethoric  and  alcoholics  require 
a  greater  amount.  The  condition  of  the  patient,  of 
course,  is  the  test  in  all  cases ;  nevertheless  it  was 
very  satisfying  under  the  gasometer  plan  when  it  was 


126  General  Ancesthetics  in  Dentistry. 

possible  to  see  the  indicator  and  note  the  number  of 
gallons  that  were  being  inhaled. 

The  induction  period  of  nitrous  oxid  gas  is  so  brief 
and  the  phenomena  occur  in  such  rapidity,  that  I  have 
not  been  able  to  make  a  satisfactory  classification  of 
symptoms.  The  four  anaesthetic  stages  are  easily  dis- 
cernible under  alcohol,  ether  and  chloroform ;  but  the 
action  is  so  quick  under  pure  nitrous  oxid  gas,  ethyl 
chloride  and  somnoform,  that  I  have  not  been  able  to 
differentiate  them.  Hewitt  has  more  thoroughly  in- 
vestigated and  experimented  with  nitrous  oxid  gas 
than  any  other  writer,  and  he  also  speaks  of  the  diffi- 
culty of  classifying  nitrous  oxid  gas  phenomena  into 
four  groups;  yet  his  intimate  knowledge  of  the  subject 
has  enabled  him  to  accomplish  this,  and  we  will  fol- 
low his  outline. 

First  Stage.  Patients  vary  greatly  in  the  matter  of 
symptoms  experienced  during  the  inhalation  of  nitrous 
oxid  gas.  This  is  to  be  expected,  because  an 
anaesthetic  does  not  destroy  one's  personality.  No 
two  patients  probably  have  an  identical  experience. 
This  is  true  in  the  more  common  things  of  life.  I  have 
been  frequently  annoyed  at  the  theater  by  those  about 
me  laughing  audibly  when  to  me  the  grouping  was  pa- 
thetic, and  at  other  times  situations  that  appealed  to 
me  as  humorous,  brought  no  smile  to  the  countenance 
of  my  neighbors.  If  you  had  an  opportunity  to  treat 
five  men  to  a  large  drink  of  whisky,  just  as  they  hap- 
pened to  be  in  a  group,  and  kept  them  together  long 
enough  to  study  the  effect,  they  would  not  react  alike 
to  this  stimulant.     One  man  would  probably  become 


General  Anccsthetics  in  Dentistry.  127 

talkative,  another  feel  like  singing,  another  become 
drowsy,  another  no  effect  at  all,  according  to  their  in- 
dividual temperament.  Even  in  the  condition  we  call 
sleep,  which  is  purely  physiological,  individuals  vary 
widely.  Some  sleep  lightly  and  are  easily  disturbed, 
while  others  sleep  profoundly  and  nothing  disturbs 
them.  Some  experience  the  wildest  kind  of  dreams, 
horrible  to  relate ;  others  in  their  dreams  have  visions 
sublime.  Just  as  the  harrowing  incidents  of  the  day 
disturl)  the  mind  to  the  degree  of  sleeplessness,  so  in 
a  disturbed  mental  state  patients  do  not  sleep  quietly 
and  tranquilly  under  an  anaesthetic.  This  condition 
and  how  to  overcome  it  is  discussed  in  the  lecture  on 
"Elements  of  Success." 

When  nitrous  oxid  is  adminstered  properly,  the  pa- 
tient having  been  made  ready  mentally  and  physically, 
the  sensations  experienced  are  more  likely  to  be  of  an 
agreeable  than  of  a  disagreeable  character.  This  is 
characteristic  of  nitrous  oxid  when  inhaled  experi- 
mentally, and,  if  it  is  not  so  when  an  operation  is  to  be 
performed,  it  shows  that  the  disturbed  mentality  inci- 
dent to  the  operation  is  the  disturbing  element  rather 
than  the  nitrous  oxid  gas. 

Should  tile  apparatus  possess  valves  which  do  not 
work  easily,  or  should  the  channels  through  which  the 
gas  is  made  to  pass  be  too  small,  or  "should  the  patient 
through  the  want  of  confidence  or  knowledge  breathe 
in  a  shallow  or  restricted  manner,  or  through  the  nose, 
an  unpleasant  experience  may  result.  Hewitt  insists 
on  mouth  breathing  when  pure  nitrous  oxid  gas  is  be- 
ing administered.     I  never  instruct  patients  in  regard 


128  General  Ancesthetics  in  Dentistry. 

to  this  point,  lest  they  become  confused,  but  in  the 
deep  breathing  required,  when  the  mouth  is  held  open 
by  a  prop,  think  there  is  a  combination  of  both  nasal 
and  mouth  inhalation  and  that  the  latter  predominates. 
An  "indescribable  pleasant  numbness  all  over  the  body 
and  a  feeling  of  warmth  in  the  lips"  are  amongst  the 
first  sensations  experienced.  Following  these  is  a 
peculiar  pleasurable  "thrilling"  which  hardly  admits  of 
description.  Then  follows,  with  some,  a  ringing  in  the 
ears,  tinnitus,  and  a  fulness  in  the  head,  caused  by  in- 
creased circulation  of  the  blood.  It  is  at  this  stage  that 
those  who  are  aiTected  unpleasantly  begin  to  hear  and 
see  things,  and  the  quicker  over,  the  better.  The  loss 
of  consciousness  comes  on  now  before  the  patient  has 
time  to  define  his  feelings.  The  pulse  grows  fuller 
under  the  finger ;  and  its  caliber  is  somewhat  increased 
at  this  stage.  The  power  of  hearing  still  persists  and 
noises  or  conversation  have  a  tendency  to  excite  the  pa- 
tient. In  my  early  anaesthetic  practice  I  used  a  small 
music  box  and  it  was  just  at  this  stage  that  the  assist- 
ant was  signalled  to  touch  it  off.  The  average  time  of 
this  first  stage,  from  the  commencement  of  the  inhala- 
tion of  nitrous  oxid  gas  till  the  loss  of  consciousness, 
is  about  thirty  seconds. 

Second  Stage.  With  the  loss  of  normal  conscious- 
ness disturbed  physical  states  arise.  As  a  rule,  the 
patient  gives  little  or  no  evidence  of  such  disturbance, 
more  especially  if  allowed  to  remain  perfectly  quiet. 
If  roughly  handled,  the  patient  is  liable  to  become  ex- 
cited and  move  his  hands  and  legs.  Any  injury  inflicted 
during  this  stage  may  produce  immediate  reflex  effects, 


General  Anccsthctics  in  Dentistry.  129 

such  as  shouting,  co-ordinate  or  inco-ordinate  move- 
ments, but  it  would  not  be  accurately  remembered  by 
the  patient.  This  stage  is  often  mistaken  by  dental 
surgeons  for  the  anaesthetic  stage  and  they  begin  to 
operate,  and  sometimes  have  disastrous  results.  The 
patient  yells,  screams,  struggles,  and  if  strong  enough 
breaks  away;  frees  himself  if  possible,  and  there  are 
instances  on  record  where  the  anaesthetist  has  suffered 
physical  violence.  Other  operators  at  this  stage,  if  the 
patient  becomes  a  little  nervous — attempts  to  move  or 
struggle — imagine  that  this  is  one  of  the  cases  in  which 
the  patient  does  not  take  nitrous  oxid  well,  "he  is 
probably  as  deep  as  I  can  get  him,  I  had  better  extract 
quickly,"  and  he  does  and  is  apt  to  have  a  fight  on  his 
hands.  A  few  more  inhalations  just  at  this  time  would 
have  induced  surgical  anaesthesia. 

Nitrous  oxid  is  often  accused  of  producing  imper- 
fect anaesthesia,  because  operations  are  sometimes  com- 
raienced  at  this  stage.  Many  nitrous  oxid  gas  appli- 
ances have  been  relegated  to  the  garret  or  laboratory 
on  account  of  the  chagrin  felt  by  the  dentist  after  an 
experience  of  this  kind  when  neither  the  appliance  nor 
the  anaesthetic  was  at  fault,  the  operator  simply  mis- 
taking the  second  stage  for  the  surgical  stage. 

Dreams  are  common,  but  are  rarely  distinctly  re- 
membered. These  depend  largely  on  the  mental  state 
of  the  patient  at  the  time  of  losing  consciousness,  and 
sometimes  on  the  kind  of  dreams  experienced  during 
natural  slecj).  I  recall  a  patient  who  had  apparently  a 
horrible  dream.  She  made  the  most  hideous  of  noises, 
and  seemed  to  be  suffering:  the  torments  of  the  damned. 


130  General  Anaesthetics  in  Dentistry. 

After  she  returned  to  consciousness,  the  friend  who  ac- 
companied her  told  me  the  patient  frequently  had  just 
such  "nightmares"  in  her  sleep  at  home.  Fortunately 
the  dreams  that  occur  under  nitrous  oxid  gas  anaes- 
thesia are  usually  of  a  pleasing  rather  than  of  a  dis- 
agreeable nature.  Hewitt  maintains  that  it  is  a  curious 
fact  that  unpleasant  dreams  are  more  common  under 
nitrous  oxid  gas  per  se  than  under  nitrous  oxid  gas  and 
oxygen,  probably  because  the  anaesthesia  in  the  latter 
case  is  deeper,  so  that  operations  or  other  interferences, 
which  in  the  case  of  nitrous  oxid  gas  itself  might  leave 
some  disturbed  impressions,  are  not  capable  of  doing 
so  when  the  anaesthesia  is  more  profound. 

In  this  stage  respiration  is  still  quicker  and 
deeper  than  normal,  and,  save  perhaps  for  an  occa- 
sional swallowing,  is  perfectly  regular.  The  pulse 
is  still  full  and  a  trifle  quicker  than  in  the  first  stage. 
In  some  cases,  a  spurious  form  of  stupor  may  occur 
and  it  is  to  be  disregarded.  The  conjunctiva  is  sensi- 
tive to  touch.  The  pupils  usually  grow  larger  as  the 
administration  proceeds.  The  eyelids  are  usually  af- 
fected by  a  slight  twitching;  and,  as  the  inhalation 
proceeds,  they  have  a  tendency  to  separate  and  to  dis- 
play the  subjacent  globes.  As  the  lids  separate  and 
the  eyeballs  become  more  prominent  and  fixed,  the 
features  lose  their  normal  color,  and  become  dusky, 
then  livid.  Blonds  are  more  susceptible  to  duskiness 
and  lividity  of  features  than  brunettes.  Sallow  people 
show  very  little  change  of  color.  At  the  close  of  this 
second  stage,  the  respiration  is  deeper  and  fuller  and 
the  pulse  stronger  than  at  any  previous  time  and  the 
patient  is  in  the  best  possible  condition. 


General  Anaesthetics  in  Dentistry.  131 


LECTURE  XL 
Nitrous   Oxid    Gas    Administration — Continued. 

Third  Stage.  The  first  indication  that  the  patient  is 
passing  or  has  passed  into  the  third  stage  of  anaesthesia 
is  usually  afforded  by  the  respiration.  The  breathing, 
which  hitherto  preserved  its  rhythm,  now  loses  it,  and 
a  peculiar  characteristic  throat  sound,  sometimes  de- 
scribed as  "stertor,"  becomes  audible.  This  sound  is 
most  probably  due  to  irregular  spasmodic  elevations  of 
the  larynx  towards  the  epiglottis  and  base  of  the 
tongue,  and  indicates  the  tendency  to  obstruction  in  the 
air-way  at  this  point.  It  occasionally  happens  that  the 
respiration  becomes  somewhat  feeble ;  or  expiration 
becomes  somewhat  prolonged  and  rather  strained. 
These  phenomena  should,  in  the  presence  of  other  signs 
of  anaesthesia,  be  taken  to  mean  that  the  administra- 
tion has  been  pushed  far  enough.  Now  is  the  proper 
time  to  begin  to  operate.  To  wait  longer  is  to  invite 
danger.  The  heart  is  still  beating  strong,  and  the  pulse 
is  very  full  and  rapid.  As  to  how  much  of  an  opera- 
tion may  be  attempted  depends  largely  upmi  the  opera- 
tor and  also  upon  the  patient.  You  can  learn  this  only 
by  experience.  Some  operators  are  more  expert  than 
others,  some  are  quicker  than  others  and  have  more 
confidence  in  themselves.    Some  dental  surgeons  seem 


132  General  Anaesthetics  in  Dentistry. 

to  know  by  intuition  when  to  cease  operating;  others 
never  seem  to  know  the  limitations  of  pure  nitrous 
oxid  gas  antesthesia.  Some  patients  are  more  pro- 
foundly anaesthetized  by  the  inhalation  of,  say,  eight 
gallons  of  nitrous  oxid  gas  than  others,  and  the  period 
of  operating  will  be  two  or  three  times  as  long.  With 
some  patients,  there  is  hardly  enough  time  to  make 
one  difficult  extraction,  while  others  as  many  as  eigh- 
teen or  twenty  teeth  may  be  removed.  Remember  that 
the  average  available  anaesthesia  inducted  by  pure 
nitrous  oxid  gas  is  only  thirty  seconds. 

A  pulse  that  was  one  hundred  and  twenty  immedi- 
ately before  the  administration  may,  for  example,  rise 
to  one  hundred  and  sixty  or  more ;  whereas  a  pulse  of 
eighty  or  ninety  at  the  beginning  of  the  inhalation  will 
not  exceed  one  hundred  or  one  hundred  and  ten  in  the 
third  stage.  Immediately  that  air  is  admitted  by  the 
withdrawal  of  the  anaesthetic,  the  pulse  abruptly  un- 
dergoes a  marked  change.  It  at  once  becomes  slower 
and  fuller.  A  pulse  at  one  hundred  and  forty  at  the 
acme  of  anaesthesia  may  suddenly  drop  to  about 
eighty  per  minute  before  the  effects  of  the  anaesthesia 
have  passed  off. 

Various  muscular  phenomena  may  appear.  When 
respiration  undergoes  the  changes  referred  to,  the  arm, 
if  raised,  will  generally  fall.  But  there  is  a  tendency 
for  clonic  muscular  contractions  to  occur  in  all  cases, 
and  for  tonic  spasm  to  arise  in  many.  In  some  cases, 
the  facial  muscles  are  chiefly  affected  by  the  convulsive 
seizure;  in  others,  the  whole  body  mildly  oscillates,  the 
spasm  apparently  chiefly  affecting  the  trunk  muscles; 


General  Ancrsthctics  in  Dentistry.  133 

in  others,  the  hands,  legs,  and  arms  alone  may  twitch ; 
whilst,  in  a  fourth  group  of  cases,  the  neck  may  be 
affected  by  barely  perceptible  clonic  spasm,  so  that  the 
head  is  felt  to  move  with  fine  rhythmic  jerks  in  one  or 
other  directions. 

Dr.  Buxton  found  that  one-third  of  the  men  and 
nearly  one-third  of  the  women  anaesthetized  by  him  at 
the  Dental  Hospital  displayed  ankleclonus  under 
nitrous  oxid. 

Micturition  rarely  occurs,  but  it  is  sometimes  met 
with  in  children.     Defecation  is  extremely  uncommon. 

The  pupils  in  a  majority  of  the  cases  are  dilated 
in  deep  nitrous  oxid  gas  anaesthesia.  In  some  cases, 
however,  they  remain  a  moderate  size  or  may  be  con- 
tracted. The  conjunctival  reflex,  which  will  have  per- 
sisted during  most  of  the  administration,  becomes  less 
marked  or  disappears.  It  can  not  be  depended  upon  as 
a  guide.     The  corneal  reflex  usually  persists. 

Fourth  Stage.  If  all  air  has  been  excluded  and  the 
patient  is  still  inhaling  pure  nitrous  oxid  gas,  there  is 
danger  now  of  an  overdose,  which  constitutes  the 
fourth  stage  of  anaesthesia.  Hewitt  has  said  that  dan- 
gerous asphyxia  will  occur  in  fifty-six  seconds  (average 
time)  if  all  air  is  excluded,  and  he  also  states  that  the 
average  time  required  to  induce  surgical  anaesthesia  is 
fifty-six  seconds.  There  is  then  no  working  margin, 
and  the  anaesthetist  should  be  extremely  careful  at 
this  stage  of  induction.  As  careful  as  we  may  be,  how- 
ever, to  exclude  air  it  is  probable  that  some  air  has  been 
admitted  to  the  lungs.  Always  be  guided  by  anaes- 
thetic symptoms — no  one  should  think  of  gauging  the 


134  General  Ancesthetics  in  Dentistry. 

time  at  which  to  operate  merely  by  the  watch.  A 
gentleman  from  Australia  gave  an  anaesthetic  clinic  at 
the  Jamestown  Exposition  Dental  Meeting.  He  would 
administer  the  anaesthetic  for  twenty-two  seconds  each 
time  by  the  watch  and  proceed  to  operate  regardless  of 
the  condition  of  his  patient. 

If  an  overdose  of  nitrous  oxid  gas  is  administered, 
the  breathing  becomes  embarrassed  and  then  ceases, 
either,  as  Hewitt,  says,  as  the  result  of  muscular  spasm 
or  by  the  more  commonly  accepted  cause,  paralysis  of 
the  respiration.  The  more  vigorous  the  patient,  the 
more  powerful  will  be  the  spasm.  At  the  time  the 
breathing  ceases,  the  color  of  the  face  is  a  deep  purple, 
sometimes  even  black,  pupils  usually  dilated,  the  eye- 
lids widely  separated,  and  the  cornea  prominent  and 
fixed.  In  strong  and  vigorous  patients,  the  heart  some- 
times continues  for  a  period  of  several  minutes,  and,  at 
the  time  that  respiration  ceases,  it  is  not  always  de- 
pressed. On  the  other  hand,  in  debilitated  patients 
with  weak  or  fatty  hearts,  delayed  respiration  will 
more  speedily  be  followed  by  cardiac  arrest.  There 
seems  to  be  no  case  on  record  in  which  death  has  re- 
sulted from  primary  circulatory  arrest,  following  the 
administration  of  nitrous  oxid  gas. 

As  pointed  out  in  previous  lectures,  it  is  all  import- 
ant to  observe  the  respiration,  for  as  long  as  the  res- 
piration is  properly  performed,  the  heart  will  take  care 
of  itself.  It  1>eh()oves  the  dental  anaesthetist  to  know 
respiration  thoroughly,  and  he  should  familiarize  him- 
self with  the  anatomy  of  the  respiratory  tract,  especial- 


General  AtucstJictics  in  Dentistry.  135 

ly  the  nerves  that  supply  and  control  the  respiratory 
muscles. 

Swollen  and  enlarged  tongue  is  common  to  pure 
nitrous  oxid  gas  anaesthesia.  This  condition  is  depend- 
ent upon  the  engorj^cment  of  the  blood  vessels  of  the 
tongue.  If  the  tongue  becomes  thus  engorged,  it  is 
probable  that  the  blood  vessels  along  the  entire  respira- 
tory tract  are  also  congested.  It  becomes  important  to 
satisfy  ourselves  whether  the  patient  has  nasal  sten- 
osis, pharyngeal  adenoids,  enlarged  tonsils,  oedema  of 
the  uvulva,  morbid  growths  of  the  soft  palate,  larynx 
or  trachea,  or  any  other  condition  that  may  impede  or 
make  more  labored  the  respiration.  When  patients  do 
not  take  nitrous  oxid  gas  well  and  become  unduly  ex- 
cited or  cyonotic  too  soon,  the  condition  probably 
arises  from  some  respiratory  obstruction,  rather  than 
from  nitrous  oxid  gas,  per  se. 

Hewitt  made  a  careful  search  of  the  dental  and 
medical  journals  for  records  of  nitrous  oxid  gas  deaths 
from  1860-1900,  and  found  but  thirty  recorded.  He  has 
placed  these  in  appropriate  groups  and  they  make  a 
most  interesting  and  profitable  study.  Class  A  he  des- 
ignates deaths  undoubtedly  due,  partly  or  wholly,  to 
nitrous  oxid  gas. 

Case  1.  l-emale,  38;  stout;  enlarged  tonsils  and 
uvulva;  dental  operation;  double  administration;  as- 
phyxia. 

Case  2.  Male,  middle-aged;  obese;  dental  opera- 
tion ;  double  administration  ;  asphyxia. 

Case   3.     Male,   57 ;   tongue    enlarged    by     morbid 


136  General  Anccsthetics  in  Dentistry. 

growth  and  fixed ;  dental  operation ;  convulsive  tremor 
and  rigidity ;  asphyxial  syncope. 

Case  4.  Male,  about  50 ;  dental  operation ;  syn- 
cope. 

Case  5.  Female,  7\  ;  stout ;  corsets  tight ;  food  in 
stomach  ;  dental  operation  ;  probably  asphyxia. 

Case  6.     Male,  24;  dental  operation,  syncope. 

Case  7.  Female,  dental  operation ;  mode  of  death 
uncertain. 

Case  8.  Male,  39;  small  and  deformed  lower  jaw; 
dental  operation ;  asphyxia. 

Case  9.  Female,  dental  operation ;  asphyxia  prob- 
ably favored  by  morbid  state  of  upper  air-passages. 

Case  10.  Male,  26;  enlarged  tonsils;  receding 
lower  jaw;  short  neck;  dental  operation;  asphyxia. 

Case  11.  Female,  23;  tight  corsets;  full  stomach; 
dental  operation ;  asphyxia. 

Case  12.     Female,  22 ;  dental  operation. 

Case  13.     Male ;  dental  operation ;  asphyxia. 

Case  14.  Male,  12;  large  abscess  in  base  of 
tongue;  fixed  lower  jaw;  opening  abscess;  asphyxia. 

Case  15.  Male,  7;  very  delicate;  old  standing  peri- 
carditis and  pleurisy ;  dorsal  posture ;  operation  for 
adenoids ;  nitrous  oxid  given  with  air ;  syncope ;  no 
obstruction  in  breathing. 

Case  16.  Female,  27 ;  food  in  stomach ;  double  ad- 
ministration ;  vomiting ;  dusky  pallor ;  syncope ;  opera- 
tion on  elbow. 

Case  17.  Male,  36;  suppuration  of  neck;  left  tonsil 
swollen;  incision  of  neck;  nitrous  oxid  with  air  first 
given  ;  then  pure  nitrous  oxid  ;  cessation  of  respiration  ; 


General  AnccstJietics  in  Dentistry.  137 

death  from  asphyxia  ;  at  necropsy,  larynx  found  to  be 
odematous. 

In  13  deaths  out  of  a  total  of  17  deaths,  the  opera- 
tion was  classified  as  dental.  And  it  would  seem  that 
in  nearly  all  of  these  deaths  some  pre-existing  condi- 
tions were  present  to  which  these  deaths  might  be  at- 
tributed. In  Case  1,  enlarged  tonsils  and  uvulva  and  a 
double  administration.  Case  2,  patient  "obese"  and 
double  administration.  Case  3,  tongue  enlarged  by 
morbid  growth.  Case  5,  corsets  tight  and  food  in 
stomach.  Case  7,  double  administration.  Case  8,  small 
and  deformed  lower  jaw.  Case  10,  enlarged  tonsils. 
Case  11,  tight  corsets  and  full  stomach. 

Out  of  the  thirteen  dental  cases,  there  were  three 
double  administrations,  two  with  tight  corsets,  and  two 
with  full  stomachs. 

Nitrous  oxid  anaesthesia  is  so  quickly  induced  and 
is  of  such  brief  duration  that  unpleasant  after-efifects 
are  generally  avoided.  Once  in  a  while,  a  patient  with 
a  very  delicate  stomach,  one  that  is  subject  to  car 
sickness  or  that  strong  odors  of  any  kind  afifect  un- 
pleasantly, may  become  nauseated.  Weakness  and  ex- 
haustion rarely  follow.  Plethoric  or  full-blooded  i)eo- 
ple,  if  they  are  subject  to  attacks  of  headache,  may  suf- 
fer a  few  hours  from  cephalgia.  Patients  more  frc- 
quentl}^  leave  the  office  stimulated  and  buoyant  than 
depressed  and  morose. 

Nitrous  oxid,  in  my  estimation,  is  not  an  ideal  den- 
tal anaesthetic.  It  is  entirely  too  brief  in  its  action  to 
be  universally  successful.  As  patients  come  to  me  to 
be  anaesthetized  from  other  operators,  more  condemn 


138  General  Aiuvstlictics  in  Dentistry. 

nitrous  oxid  than  praise  it.  Occasionally  some  one  will 
say,  "My  experience  with  nitrous  oxid  was  pleasant, 
the  operation  a  success,  and  I  would  even  go  to  Chi- 
cago rather  than  have  a  tooth  extracted  without  it." 
For  every  expression  of  this  kind  I  hear  ten  who  de- 
clare with  them  nitrous  oxid  was  a  failure.  Not  only 
was  the  pain  inflicted  severe,  but  it  was  accompanied 
with  a  hideous  nightmare.  Those  dental  surgeons 
who  are  successful  in  administering  nitrous  oxid  will 
think  that  I  have  overstated  the  case,  but  the  hundreds 
of  dentists  who  have  discarded  their  gasometers  and 
have,  some  of  them,  two  or  three  kinds  of  nitrous  oxid 
appliances  hid  away  in  closets  and  laboratories  will 
say  that  I  have  understated  rather  than  overdrawn  the 
situation. 

Thirty  seconds  of  available  anaesthesia  are  not  suffi- 
cient for  dental  purposes.  It  is  entirely  too  brief  for 
the  average  dental  surgeon  and  it  is  the  average  den- 
tist that  must  be  satisfied.  Even  our  most  skilled  den- 
tal anaesthetists  and  our  expert  extracting  specialists 
are  many  times  defeated  in  accomplishing  a  certain 
operation  on  account  of  the  brevity  of  pure  nitrous 
oxid  anaesthesia. 

Its  greatest  advantage  is  its  safet}-.  It  is  safe  only 
because  the  patient's  behavior  and  appearance  are  such 
that  the  dental  surgeon  has  not  the  courage  to  push 
the  anaesthetic  even  to  the  proper  stage  for  operating, 
and  makes  a  sad  failure.  The  bulging  eyeballs,  the 
dusk}^  complexion,  the  stertorous  breathing,  the  con- 
tortion of  the  face  muscles  and  the  distressed  appear- 
ance of  the  patient  frightens  the  dentist  into  operating 


General  Aiicrsthetics  in  Dentistry.  139 

too  soon,  but  no  doubt  saves  the  life  of  the  patient  in 
many  cases. 

Hewitt  has  said  it  is  a  dangerous  procedure  to  ex- 
clude air  for  more  than  fifty-six  seconds  when  pure 
nitrous  oxid  is  being  inhaled,  and  he  also  says  that  the 
average  time  required  to  induce  surgical  anaesthesia 
with  nitrous  oxid,  with  all  air  excluded,  is  fifty-six 
seconds,  so  it  is  evident  that  according  to  the  acknowl- 
edged nitrous  oxid  authority,  the  point  of  surgical  an- 
aesthesia and  the  danger  point  are  the  same. 

The  dental  surgeon  in  nearly  all  cases  makes  a  fail- 
ure of  nitrous  oxid ;  the  extracting  specialist  through 
long  training  and  frequent  daily  use  knows  the  possi- 
bilities and  limitations  of  pure  nitrous  oxid.  But  there 
is  only  about  one  extracting  specialist  to  each  thousand 
dentists. 

Pure  nitrous  oxid  as  an  anaesthetic  has  had  its  day. 
Only  in  the  most  simple  cases  of  extracting  should  it 
be  used,  if  at  all.  Indeed,  there  is  no  longer  a  necessity 
for  employing  this  anesthetic  agent. 

It  has  been  demonstrated  that  by  adding  definite 
proportions  of  oxygen  to  nitrous  oxid,  instead  of  an 
available  anaesthesia  of  thirty  seconds,  an  indefinite 
anaesthesia  can  be  maintained. 

Not  only  can  prolonged  anaesthesia  be  maintained, 
but  a  safe  anaesthesia.  Anaesthesia  is  now  possible 
without  cyanosis,  without  jactitation,  without  ap- 
proaching the  danger  line,  as  very  few  deaths  have 
ever  been  reported  as  arising  from  nitrous  oxid  and 
oxygen  anaesthesia. 

Before  discussing  nitrous  oxid  and  oxygen,  which 


140  General  Ancvsthetics  in  Dentistry. 

naturally  should  be  considered  now,  I  wish  to  call  your 
attention  to 

Nitrous  Oxid  Warmed. 

I  have  learned  that  nitrous  oxid  warmed  is  superior 
to  nitrous  oxid  cold  as  an  anaesthetic.  An  appliance 
formerly  used  by  me  when  teeth  were  to  be  extracted 
or  for  surgical  operations  had  a  thermometer  in  the 
"mixing-chamber,"  and  I  knew  the  temperature  when 
nitrous  oxid  left  that  chamber  if  not  when  it  entered 
the  lungs.  Although  I  knew  that  nitrous  oxid  as  it 
passed  out  of  the  rubber  bag  was  cold,  I  did  not  realize 
till  I  made  the  test  for  myself  that  the  cold  was  so  in- 
tense as  it  passed  into  the  lungs.  For  an  ordinary  case 
of  extracting  in  which  eight  or  nine  gallons  of  the  gas 
is  consumed  the  thermometer  falls  to  20°  F. — or  twelve 
degrees  below  the  freezing-point.  In  prolonged  cases 
I  have  seen  the  thermometer  settle  to  10°  F.  The  gas 
passes  first  into  the  rubber  bag,  then  into  the  "mixing- 
chamber,"  containing  the  thermometer,  and  from  there 
through  the  tubing  to  the  inhaler  and  the  nose.  How 
much  the  temperature  of  gas  is  raised  passing  through 
four  feet  of  tubing,  the  nares  and  pharynx,  rapidly  in- 
haled, I  do  not  know.  But  I  do  know  that  the  mucous 
membrane  over  which  the  gas  passes  so  rapidly  be- 
comes chilled,  and  that  we  are  not  warranted  in  turn- 
ing such  a  cold  draft  into  the  bronchi  and  lungs.  In  a 
conversation  recently  with  one  of  our  leading  phy- 
sicians I  was  advocating  the  use  of  nitrous  oxid  pre- 
liminary to  ether  and  chloroform.  He  remarked,  "That 
was  my  custom  for  years,  but  it  was  productive  of  so 


General  Ancrsthetics  in  Dentistry.  141 

much  bronchial  and  lung  trouble  on  account  of  the  irri- 
tating properties  of  the  gas  that  I  abandoned  its  use." 
"Why,  man,"  I  said,  "nitrous  oxid  is  not  irritating." 
He  insisted  that  it  was.  Then  I  asked  him  if  he  knew 
the  temperature  of  nitrous  oxid  as  it  left  the  bag  to 
enter  the  lungs  ;  he  said  "no."  I  informed  him — a 
blank  look  came  over  his  face.  In  a  moment  he  said, 
"It  was  the  extreme  cold,  then,  that  caused  my  cases 
of  bronchitis  and  pneumonia,  was  it  not?"  I  know  if 
I  remove  my  collar  and  the  mildest  kind  of  a  draft 
strikes  the  back  of  my  neck,  I  have  a  cold  and  a  stifif 
neck  next  day.  If  the  outside  of  the  neck  is  so  sensi- 
tive to  thermal  changes,  I  should  think  the  inside 
would  become  involved  if  I  breathed  deeply  and  rapid- 
ly a  gas  which  entered  my  nose  at  a  temperature  of  10°- 
20° — below  freezing-point. 

With  the  gas  warmed,  the  patient  passes  into  as 
quiet  and  as  beautiful  an  anaesthesia  as  we  obtain  with 
somnoform.  No  jactitation,  seldom  yelling,  scream- 
ing and  laughing  so  common  with  the  usual  method, 
and  by  admitting  a  small  quantity  of  oxygen,  no  dis- 
coloration or  asphyxia. 

I  have  administered  nitrous  oxid  cold,  thirty-three 
years  and  nitrous  oxid  warm  fourteen  years,  and  I  have 
not  the  language  at  my  command  to  tell  you  how 
pleased  I  am  with  warm  nitrous  oxid. 

Specialists  who  limit  their  practice  to  extracting 
teeth  under  nitrous  oxid  anaesthesia,  who  manufacture 
their  own  nitrous  oxid,  maintain  it  at  the  same  tem- 
perature as  the  atmosphere  of  the  operating-room,  and 
this  is  one  reason  why  they  get  so  much  better  results 


142  General  Ancrsthetics  in  Dentistry. 

than  the  man  who  relies  on  the  ordinary  gas  cylinder 
for  his  supply  of  nitrous  oxid. 

I  may  be  mistaken,  but  it  is  my  belief  that  much 
of  the  struggling,  the  jactitation,  the  wild  dreams  and 
horrible  nightmares  experienced  so  frequently  during 
nitrous  oxid  anaesthesia  are  caused  by  the  cold  nitrous 
oxid  stimulating  the  nerves  of  the  bronchi  and  lungs 
and  they  in  turn  reflexly  communicating  with  the  cen- 
tral nervous  system.  However  this  may  be,  I  do  know 
that  with  the  method  I  am  now  using  of  warming  the 
gas  the  anaesthesia  resulting  is  quiet  and  peaceful  and 
free  from  dreams  or  visions  of  an  annoying  character. 

Most  of  the  new  anaesthetic  appliances  have  a 
warming  device  through  which  the  nitrous  oxid  passes, 
raising  the  temperature  to  about  85-90°  F.  If  all  anaes- 
thetics were  inhaled  at  a  temperature  equal  to  that  of 
the  body  the  anaesthetic  agent  would  be  more  quickly 
assimilated  by  the  blood  and  more  easily  eliminated 
from  the  system  and  would  do  much  to  maintain  a 
normal  body  temperature  throughout  the  period  of  an- 
aesthesia. 


General  Anwstlietics  in  Dentistry.  143 


LECTURE  XII. 
Nitrous  Oxid  and  Oxygen. 

Oxygen  is  a  supporter  of  life,  but  nitrous  oxid  gas 
is  not.  Priestly,  who  discovered  both  nitrous  oxid  and 
oxygen,  reported  some  very  interesting  experiments. 
He  placed  small  animals  under  two  receivers,  one  filled 
with  oxygen  and  the  other  air.  Those  under  the  re- 
ceiver filled  with  oxygen  lived  twice  as  long  as  those 
under  the  receiver  filled  with  the  air.  The  death  of 
birds  in  the  receiver  filled  with  oxygen  transpired  with- 
out convulsions  while  the  death  of  the  birds  in  the  re- 
ceiver containing  air  was  always  accompanied  by  con- 
vulsions. The  heart  retains  its  irritability  for  hours 
when  death  takes  place  in  oxygen,  but  this  is  not  the 
case  when  death  takes  place  in  air.    [Gwathmey.] 

"Demarquay  immersed  two  kittens  in  water  and 
kept  them  there  until  they  had  lost  consciousness  and 
were  completely  asphyxiated.  One  had  been  previ- 
ously confined  for  twenty  minutes  in  a  glass  case  con- 
taining two  parts  oxygen  and  one  of  air,  the  other  had 
breathed  only  atmospheric  air.  On  removing  them 
from  the  water  there  was  only  a  slight  movement  of 
the  lower  jaw.  At  the  end  of  a  minute  and  a  half  the 
supcroxygenated  kitten  arose  and  totteringly  walked 
around  and  made  an  uneventful  recovery.    The  other 


144  General  Aiiarsthetics  in  Dentistry. 

partially  recovered  at  the  end  of  fifteen  minutes,  but 
died  the  next  day.  These  experiments  were  repeated 
a  number  of  times,  but  always  with  the  same  results." 
(Gwathmey.)  I  stated  in  the  last  lecture  that  nitrous 
oxid  when  inhaled  does  not  resolve  itself  into  its  com- 
ponent parts,  but  remains  as  nitrous  oxid.  If  you  add 
pure  oxygen  to  the  nitrous  oxid  gas  and  then  inhale  it, 
something  very  dififerent  may  happen.  Some  of  the 
oxygen  inhaled  passes  into  the  blood  to  form  a  loose 
chemical  combination  with  the  red  corpuscles ;  oxy- 
hamaeglobin.  Life  in  this  way  can  be  supported  in- 
definitely, the  oxygen  supplying  food  for  the  blood, 
which  in  turn  feeds  the  tissues  while  the  nitrous  oxid 
is  anaesthetizing  the  patient. 

Is  it  not  reasonable,  then,  that  I  should  recommend 
the  use  of  nitrous  oxid  gas  plus  oxygen  in  all  cases  in 
which  nitrous  oxid  is  indicated?  With  nitrous  oxid, 
the  period  of  available  anaesthesia  is  but  30  seconds ; 
with  nitrous  oxid  and  oxygen,  you  can  operate  as  long 
as  you  wish.  With  pure  nitrous  oxid,  when  all  air  is 
excluded,  "the  average  inhalation  period  is  fifty-six 
seconds ;  at  the  end  of  that  time,  fresh  oxygen  must 
be  admitted  or  permanent  asphyxia  will  result" 
(Hewitt)  ;  while  with  nitrous  oxid  and  oxygen,  in 
proper  proportions,  there  is  no  asphyxia.  All  deaths 
arising  from  nitrous  oxid  are  supposed  to  have  been 
caused  by  asphyxia.  The  clonic  muscular  spasms  or 
"jactitation"  so  common  under  nitrous  oxid  rarely  oc- 
curs under  nitrous  oxid  and  oxygen. 

While  Andrews,  of  Chicago,  was  the  first  to  use 
nitrous  oxid  and  oxygen  as  an  anaesthetic,  Hillischer, 


General  Anaesthetics  in  Dentistry.  145 

of  Vienna,  was  the  first  dentist  to  systematically  em- 
ploy nitrous  oxid  and  oxygen  in  definite  proportions. 
He  states  that  he  "has  administered  'Schlafgas'  to  pa- 
tients of  all  ages;  to  those  suffering  from  advanced 
affections  of  the  heart;  to  those  with  diseases  of  the 
lungs;  and  to  the  subjects  of  epilepsy  and  other  ner- 
vous diseases.  He  further  states  that  he  looks  upon 
this  gaseous  mixture  as  absolutely  without  contra-in- 
dication — that  he  administers  it  to  every  patient  irre- 
spective of  any  morbid  state  which  may  be  present. 
He  admits  that  more  experience  is  needed  in  adminis- 
tering 'Schlafgas'  (nitrous  oxid  and  oxygen)  than  in 
giving  any  other  anaesthetic  with  which  we  are  ac- 
quainted ;  and  there  can  be  no  doubt  that  here,  again, 
he  is  correct."  (Hewitt.) 

Apparatus. 

All  modern  nitrous  oxid  appliances  are  so  arranged 
that  oxygen  can  be  administered  in  combination  with 
nitrous  oxid  gas  in  definite  proportions.  This  is  ac- 
complished by  the  addition  of  a  cylinder  of  oxygen  at- 
tached to  the  appliance  in  a  convenient  position.  A 
second  rubber  bag  is  used  to  contain  the  Oxygen. 
These  appliances  have  a  "mixing-chamber."  The 
nitrous  oxid  gas  passes  from  its  cylinder  into  its  rubber 
bag  and  from  thence  into  the  mixing-chamber.  The 
oxygen  passes  likewise  from  the  oxygen  cylinder  into 
the  oxygen  bag,  from  which  it  finds  its  way  also  into 
the  mixing-chamber.  The  two  gases  combine  here  in 
the  proportions  desired. 

There  is  a  d^vig?  §q  adjusted  that  the  amount  of 


146  General  Ancesthetics  in  Dentistry.    . 

oxygen  passing  out  of  the  oxygen  bag  can  be  con- 
trolled or  regulated.  Although  not  scientifically  accu- 
rate, it  is  an  advance  in  the  right  direction. 

The  amount  of  oxygen  necessary  to  prevent  cyano- 
sis and  muscular  spasm  varies  somewhat  with  the  in- 
dividual. If  we  rely  upon  the  oxygen  in  the  air  to  over- 
come spasm  and  cyanosis,  so  much  air  is  necessary  that 
it  modifies  anaesthesia.  On  an  average,  it  requires 
about  8%  of  oxygen,  and  in  order  to  abstract  that  much 
oxygen  from  the  air  it  would  require  40^  of  air.  It 
requires  about  92%  of  nitrous  oxid  to  ansesthetize  a 
patient  deeply,  so  it  is  evident  that  if  we  admit  40% 
of  air  in  order  to  obtain  8%  of  oxygen,  we  have  left 
only  60%  of  nitrous  oxid,  which  is  about  32%  short  of 
the  average  amount  necessary  to  induce  deep  anaes- 
thesia. In  other  words,  in  the  40%  of  air  which  must 
be  inhaled  along  with  the  nitrous  oxid  in  order  to  fur- 
nish 8%  of  oxygen  there  is  32%  of  nitrogen  that  we  do 
not  need  at  all.  It  is  evident,  then,  that  when  we  uti- 
lize the  air  to  furnish  the  requisite  8%  of  oxygen,  we 
have  only  60%  of  nitrous  oxid  for  anaesthetic  purposes, 
but  when  we  admit  8%  pure  oxygen  direct  from  a 
cylinder  we  have  then  92%  of  nitrous  oxid  for  the  pur- 
pose of  inducing  anaesthesia. 

It  has  been  my  experience  that  just  a  little  air  ad- 
mitted along  with  nitrous  oxid  is  disadvantageous.  It 
prolongs  the  induction  of  anaesthesia,  increases  excite- 
ment, and  there  is  more  jactitation.  Hewitt's  experi- 
ments show  that  patients  can  be  anaesthetized  when  air 
is  admitted  up  to  30%.  But  with  30%  of  air  it  re- 
quired 148  seconds  to  induce  anaesthesia.    With  33% 


General  Anccsthctics  in  Dentistry.  147 

of  air  he  failed  to  induce  anaesthesia.  With  3%  to  5% 
of  air  the  average  inhalation  period  was  69  seconds. 

It  is  well  to  remember  that  the  higher  the  percent- 
age of  air  admitted,  the  longer  it  will  take  to  induce 
anaesthesia  and  the  lighter  will  be  the  resultant  anaes- 
thesia, not  on  account  of  the  oxygen  that  is  abstracted 
from  the  air,  but  on  account  of  the  smaller  amount  of 
nitrous  oxid  that  enters  the  lungs  with  each  inhalation. 

It  becomes  very  much  easier  and  far  more  accurate 
to  rely  upon  oxygen  in  a  cylinder  than  to  depend  upon 
abstracting  oxygen  from  the  air.  By  thus  administer- 
ing nitrous  oxid  and  oxygen,  excluding  all  air,  patients 
can  be  surgically  anaesthetized  indefinitely.  Teter,  of 
Cleveland,  recently  anaesthetized  a  large,  obese  and 
plethoric  patient,  for  a  currettement  and  ovariotomy, 
the  patient  being  under  the  influence  of  nitrous  oxid 
and  oxygen  for  two  hours  ond  forty-eight  minutes, 
without  one  breath  of  air.  Nearly  600  gallons  of  ni- 
trous oxid  and  80  gallons  of  oxygen  were  used.  The 
writer  was  present  on  one  occasion  when  Teter  main- 
tained surgical  anaesthesia  for  a  period  of  two  hours 
and  thirty  minutes  without  a  breath  of  air.  The  pa- 
tient returned  to  consciousness  in  less  than  two  min- 
utes after  discontinuing  the  anaesthetic. 

Administration. . 

Nitrous  oxid  and  oxygen,  unfortunately,  is  the 
most  difficult  of  all  anaesthetics  to  administer.  It  is 
without  doul)t  the  safest  of  all  anaesthetics  and  but  for 
the  difficulties  attending  its  adminstration  would  be 
the  most  popular  and  most  generally  used  of  all  anaes- 


148  General  Ancusthetics  in  Dentistry. 

thetics.  I  have  already  spoken  of  the  difficulties  inci- 
dent to  administering  pure  nitrous  oxid,  and,  in  addi- 
tion to  these,  we  have  the  added  responsibility  of  feed- 
ing the  oxygen  in  the  right  proportions  at  the  right 
time.  It  is  something  that  must  be  learned  by  re- 
peated administrations.  The  more  familiar  you  are 
w^ith  administering  pure  nitrous  oxid  the  quicker  will 
you  become  proficient  in  administering  this  combined 
anaesthetic. 

Just  as  with  pure  nitrous  oxid,  some  individuals  and 
some  types  are  more  susceptible  than  others.  People 
enjoying  robust  health,  strong  and  muscular,  full- 
blooded  and  active  are  not  as  favorable  subjects  as 
the  frail,  the  physically  weak,  and  those  of  tranquil 
temperament.  All  people  who  drink  or  smoke  to  ex- 
cess, whether  coffee,  tea  or  liquors,  drug  fiends  and 
alcoholics,  and  those  addicted  to  cigarettes  and  chew- 
ing tobacco  are  more  difficult  to  anaesthetize  by  this 
method  than  those  of  temperate  habits. 

Much  depends,  of  course,  on  proper  breathing; 
hence  stenoses  and  obstructions  of  any  kind  whatso- 
ever in  the  mouth,  nose,  pharynx,  larynx,  trachea,  bron- 
chi or  the  lungs  interfere  more  or  less  with  inducing 
comfortable  and  successful  anaesthesia.  At  times  when 
the  patient  does  not  succumb  to  the  anaesthetic  as 
quickly  as  usual,  showing  signs  of  distress  and  discom- 
fort, an  examination  will  often  disclose  hypertrophied 
turbinated  bones ;  deviated  septum ;  nasal  polyp  or 
polypi;  enchondroma  or  osteoma  in  the  nares ;  adeno- 
ma or  other  growths  in  the  pharynx ;  cleft  palate,  hard, 
goft,  or  both ;  odoematous  or  elongated  uvulva ;  en- 


General  Aiucsthetics  in  Dentistry.  149 

larged  tonsils  ;  enlarged  thyroid  gland  ;  impaired  lungs, 
or  lungs  restricted  in  their  action  by  adhesions,  the  re- 
sult of  former  intiammatory  affections  or  the  presence 
of  pus  cavities  or  encroachment  on  the  lungs  of  various 
enlargements  and  tumor  formations.  The  anaesthetic 
itself  is  not  always  to  blame  for  imperfect  anaesthetiza- 
tion. 

When  a  prolonged  anaesthesia  is  to  be  induced,  the 
patient  must  be  as  carefully  prepared  as  for  ether  or 
chloroform.  Everything  that  has  been  said  in  regard 
to  the  chair,  the  assistant,  the  mouth-prop,  suggestion, 
arrrangement  of  instruments,  etc.,  in  the  lecture  on  ni- 
trous oxid  is  applicable  here.  All  these  matters,  as 
insignificant  as  they  may  appear  to  you,  must  be  ob- 
served if  you  wish  to  be  successful  in  administering 
nitrous  oxid  and  oxygen  for  dental  purposes. 

While  a  good  assistant  is  essential  to  success  with 
pure  nitrous  oxid,  with  nitrous  oxid  and  oxygen  it  is 
imperative.  Hundreds  of  nitrous  oxid  appliances  have 
been  discarded,  others  literally  thrown  out  of  the  office 
by  discouraged  and  often  disgusted  operators,  because 
of  failure  to  get  satisfactory  results,  the  supposed  fault 
not  being  with  either  the  nitrous  oxid  and  oxygen  or 
with  the  appliance,  but  mostly  because  of  lack  of  in- 
telligent assistance. 

All  preliminary  arrangements  having  been  made, 
the  patient  is  now  ready  to  be  anaesthetized.  The  "O" 
bag  should  be  filled  almost  full  of  oxygen  and  the 
"NO"  bag  about  two-thirds  full  of  nitrous  oxid.  There 
should  really  be  considerable  tension  on  these  rubber 
bags,  but  not  enough  to  explode  them.    Place  the  in- 


150 


General  Anesthetics  in  Dentistry. 


haler  over  the  mouth  and  nose  with  the  anaesthetic 
shut  off.  Have  the  patient  breathe  deeply  and  evenly 
two  or  three  times  to  test  the  valves  and  to  see  that 
the  adjustment  is  such  as  to  exclude  all  air.     You 


NO.  2  LENNOX  STAND. 

These  cylinders  can  be  placed  at  some  distance  from  the  chair, 
in  another  room  if  desired,  and  connected  with  the  appliance  by 
means  of  small  rubber  tubing. 

judge  by  the  sound  of  the  valves  as  to  whether  they 
are  in  good  working  order.  Satisfied  on  this  point,  the 
anaesthetic  may  now  be  admitted.  The  first  few  inhala- 
tions should  be  of  pure  nitrous  oxid.  As  soon  as  duski- 


General  Anccsthetics  in  Dentistr^' 


151 


ness  of  the  face  is  observed,  turn  the  oxygen  indicator 
to  "1"  at  first,  then  "2,"  and  as  the  anaesthesia  ad- 
vances, to  "4"  or  "6"  gradually.    If  you  should  begin 


^l!^ 


Clark  Appliance,   Lenuox  Carriage,  large  cylinders  with   pressure 

Gauges. 


with  "6"  or  "8,"  the  patient  would  manifest  signs  of 
restlessness  and  excitement. 

The  frail,  the  delicate  and  the  anaemic  will  admit  of 


152  General  Ancesthetics  in  Dentistry. 

oxygen  in  larger  proportion  in  the  beginning  than  the 
vigorous,  the  plethoric  and  the  athletic.  With  the 
average  patient  you  can  advance  the  indicator  five 
points  in  about  thirty  seconds,  and  in  fifty-nine  or 
sixty  seconds  to  "8."  The  indication  for  more  oxygen 
is  the  color  of  the  face.  There  is  no  other  rule.  If  the 
face  assumes  a  dusky  hue,  the  indicator  may  be  ad- 
vanced still  further.  In  the  absence  of  duskiness  and 
a  tendency  on  the  part  of  the  patient  to  laugh  or  cry 
or  move  the  hands  and  legs,  the  indicator  should  be  set 
back  a  number  or  two.  It  is  important  that  the  amount 
of  oxygen  in  the  "O"  bag  should  be  equal  to  the 
amount  of  nitrous  oxid  in  the  "NO"  bag.  If  this  is 
not  the  case,  the  nitrous  oxid  will  have  more  force  be- 
hind it  than  the  oxygen  and  the  proportions  can  not  be 
maintained.  By  the  use  of  the  larger  cylinders  equip- 
ped with  pressure  regulators,  an  equal  pressure,  and 
the  same  number  of  pounds  of  pressure  for  each  gas 
can  be  obtained.  As  already  mentioned  in  a  previous 
lecture,  there  should  be  no  conversation  allowed  while 
anaesthetizing  the  patient.  Sounds  are  exaggerated, 
and  the  sense  of  hearing  remains  intact  till  the  close  of 
the  third  stage  and  with  some  patients  is  not  lost. 
Talking  back  and  forward  between  the  operator  and 
the  assistant,  "do  this  and  do  that,"  is  enough  to  defeat 
any  anaesthesia.  Suggestions  to  the  patient  in  a  low, 
quiet,  but  firm  tone  of  voice,  looking  to  thje  quieting 
of  the  patient  is  the  only  conversation  permissible  dur- 
ing the  induction  of  anaesthesia  when  the  assistant  is 
operating  the  appliance.  If  I  wish  more  oxygen,  "O" 
is  made  with  the  thum1)  and  first  finger;  if  more  nitrous 


V 

i. 


General  Ancpsthetics  in  Dentistry.  153 


1  oxid,  two  fingers  are  raised,  representing  an  "N."  If  I 

wish  the  oxygen  reduced,  an  "O"  with  the  fingers  and 
y. .'  one  nod  of  the  head  at  the  same  time  means  set  the 

y  oxygen    indicator    back    one     notch,     two    nods     two 

f  notches,  etc.    An  "N"  with  the  nod  of  the  head  means 

a  reduction  in  flow  of  the  gas,  two  nods  a  greater  re- 
duction.   With  the  new  appHances,  one  lever  controls 
''  both    the    nitrous   oxid    and   ox\'gen   supply,    and   the 

1.  operator  can  act  as  aUcESthetist,  if  he  so  wishes,  until 

ready  to  operate.   Two  persons  soon  learn  to  work  to- 
-;  gether  with  signals  as  successfully  as  a  base-ball  bat- 

y  tcry.    The  longer  the  anaesthesia,  the  more  oxygen  will 

the  patient  consume  as  the  anaesthesia  progresses.   Dif- 
[^  ferent  appliances  may  vary  somewhat.     I  find  about 

"8"  per  cent,  or  rather  when  the  indicator  is  at  "8," 
I  get  the  best  results,  on  the  average,  in  dental  opera- 
tions. 

For  a  simple  case  of  extraction,  say  two  or  three 
teeth,  for  which  it  would  require  fifty  seconds  to  ob- 
tain an  available  anaesthesia  of  thirty  to  thirty-five  sec- 
onds with  pure  nitrous  oxid,  an  administration  of  ni- 
trous oxid  and  oxygen  for  a  period  of  about  one  hun- 
dred and  ten  to  one  hundred  and  fifteen  seconds,  would 
afford  an  average  available  anaesthesia  of  about  forty- 
five  seconds.  The  patient  in  the  former  case,  in  which 
pure  nitrous  oxid  was  administered,- would  be  cyan- 
otic and  on  the  border  line  of  dangercnis  asphyxia  ;  in 
the  latter  case,  enough  oxygen  would  be  inhaled  to 
prevent  all  cyanosis  and  asphyxial  symptt>nis. 

The  First  Stage  of  nitrous  oxid  and  oxygen  does 


154  General  AncBsthetics  in  Dentistry. 

not  vary  materially  from  the  first  stage  of  pure  nitrous 
oxid. 

The  Second  Stage  is  more  prolonged  than  the  sec- 
ond stage  of  pure  nitrous  oxid,  because  the  patient  does 
not  lose  consciousness  as  quickly.  Respiration  fre- 
quently becomes  very  rapid  and  deep,  and,  if  the  pa- 
tient shows  signs  of  excitement,  too  much  oxygen  is 
being  inhaled  and  the  amount  should  be  reduced.  As 
anaesthesia  deepens,  the  stertor,  incident  to  the  last 
part  of  the  second  stage  of  nitrous  oxid  anaesthesia,  is 
replaced  by  gentle  snoring;  the  dusky  cyanotic  condi- 
tion of  the  pure  nitrous  oxid  stage  is  wanting  and  in 
its  place  a  normal  complexion. 

The  Third  Stage,  or  the  Stage  of  "Surgical  Anaes- 
thesia," is  the  one  in  which  the  difference  is  more 
marked.  Instead  of  deep  cyanosis  and  loud  stertor, 
the  patient  has  the  appearance  of  one  in  a  natural  sleep, 
and  even  the  gentle  snoring  of  the  second  stage  disap- 
pears. The  breathing  is  regular  and  quiet.  You  will 
remember  in  the  lecture  on  nitrous  oxid  that  I  called 
your  attention  to  the  fact  that  the  tongue  became  en- 
larged on  account  of  engorgement  of  venous  blood, 
and  suggested  that  if  the  tongue  was  engorged  the 
same  condition  must  be  present  in  a  greater  or  less  de- 
gree throughout  the  respiratory  tract.  This  swelling 
of  the  tongue  is  markedly  less  when  anaesthesia  is  in- 
duced by  nitrous  oxid  and  oxygen,  and,  of  course,  the 
breathing  would  be  less  interrupted,  and  in  case  the  pa- 
tient should  happen  to  have  adenoids,  enlarged  tonsils, 
nasal  polypi,  etc.  (such  conditions  being  very  com- 
mon), there  would  not  be  the  same  inconvenience  and 


General  Aiucstlictics  in  Dentistry.  155 

danger  as  would  be  assumed  in  administering  pure 
nitrous  oxid.  In  this  stage,  the  pulse  is  strong,  but  not 
as  rapid  or  small  as  the  pulse  in  the  third  stage  of  pure 
nitrous  oxid.  It  is  very  much  more  like  the  normal 
pulse,  just  as  the  breathing  and  the  complexion  is  more 
nearly  normal. 

The  eyelids  instead  of  being  rolled  back,  exposing 
the  eyeballs,  are  usually  closed.  The  pupils  remain 
more  nearly  normal  than  otherwise,  and  the  cornea 
is  generally  sensitive  to  touch,  and  does  not  lose  its 
sensitiveness  during  brief  anaesthesias. 

The  signs  of  anaesthesia  are  very  much  the  same  as 
those  of  chloroform.  The  arm  if  raised  falls  limp.  The 
breathing  is  usually  quiet  and  regular,  and  sometimes, 
by  listening  closely  indistinct  snoring  may  be  detected, 
the  degree  depending  somewhat  on  the  normality  or 
abnormality  of  the  respiratory  channel.  The  conjunc- 
tival reflex  is  lost,  and  the  eyeballs  are  fixed  or  may 
move  slightly  from  side  to  side,  but  in  a  much  milder 
degree  than  is  found  in  anesthesia  induced  by  pure  ni- 
trous oxid. 

The  Fourth  Stage  in  nitrous  oxid  and  oxygen  anres- 
thesia  is  wanting.  The  toxic  dose  of  this  anaesthetic  is 
not  known.  Only  a  few  deaths  have  been  reported 
during  nitrous  oxid  and  oxygen  anaesthesia.  I  have 
tried  to  conceive  in  what  way  or  by  what  means  death 
could  come  under  nitrous  oxid  and  oxygen  properly 
administered.  Surely  not  from  asphyxia  as  in  pure 
nitrous  oxid  narcosis;  not  from  protoplasmic  poison- 
ing as  with  chloroform  :  not  ])y  respiratory  paralysis 
as  with  ether.    For  purely  dental  purposes,  eliminating 


156  General  Ancrsthetics  in  Dentistry. 

fright  and  all  physical  causes,  eliminating  a  tooth 
lodging  in  the  trachea,  or  shock,  the  result  of  blood 
collecting  in  the  throat,  both  of  which  are  incidental 
causes  only,  I  cannot  conceive  of  death  occurring  as 
the  result  of  administering  nitrous  oxid  and  oxygen. 

Nitrous  Oxid — Oxygen — Carbon  Dioxid — Anaesthesia. 

Investigations  made  in  the  United  States  the  past 
two  or  three  years  by  Yandell  Henderson  and  associ- 
ates of  New  Haven,  Mosso  of  Turin,  and  others  abroad, 
have  proven  beyond  doubt  that  carbon  dioxid  is  not  as 
formerly  supposed  a  waste  product  of  the  body,  but 
that  it  is  one  of  the  body's  most  important  hormones. 
It  exercises  a  regulative  influence  on  the  action  of  the 
heart,  on  the  tonus  of  the  blood  vessels,  and  especially 
upon  the  respiration.  In  fact,  breathing  in  ordinary 
life  is  practically  dependent  on  the  stimulation  afforded 
to  the  respiratory  center  by  the  carbon  dioxid  brought 
to  it  in  the  blood.  (Ettore  Levi,  Florence,  Italy.)  A 
discovery  of  greater  importance  than  this  to  anaes- 
thetists can  hardly  be  conceived.  After  reading  Hen- 
derson's paper  Levi  was  inspired  to  experiment  with 
mixtures  of  carbon  dioxid  for  the  purpose  of  stimulat- 
ing the  bulbar  centers  in  those  cases  in  surgical  prac- 
tice in  which,  owing  to  the  effects  of  chloroform  and 
ether  or  to  operative  trauma,  or  to  a  combination  of 
these  causes,  the  automatic  activity  of  these  centers  is 
temporarily  paralyzed.  The  experiments  of  Levi 
showed  that  in  carbon  dioxid  properly  diluted  we  pos- 
sess a  therapeutic  agent  of  extraordinary  potency.  He 
experimented  on  animals,  inducing  failure  of  the  res- 


General  /Inccsthctics  in  Dentistry.  157 

piration  by  means  of  the  single  or  combined  action  of 
nitrites,  chloroform,  and  morphin.  These  animals 
were  then  made  to  inhale  a  mixture  of  oxygen  with 
various  percentages  of  carbon  dioxid — from  10-30%. 
In  every  case  there  was  an  almost  immediate  return  of 
breathing.  He  then  tried  the  administration  of  these 
gas  mixtures  to  patients  who,  because  of  trauma  or  ex- 
tensive or  prolonged  operation,  had  sunken  into  a  par- 
tial or  completely  comatose  state.  The  effects  were  at 
times  brilliant,  especially  in  those  cases  where  the 
breathing  had  become  shallow,  or  irregular.  The  most 
satisfactory  results  were  obtained  with  a  mixture  con- 
taining 15  per  cent  of  carbon  dioxid.  In  cases  where 
the  respiration  was  decreased  (Cheyenne-Stokes  type) 
the  periodic  rhythm  was  immediately  stopped  and  nor- 
mal breathing  was  not  only  restored,  but  continued 
some  time  after  the  inhalation  was  ended.  In  such 
cases  not  only  was  respiration  improved,  but  there  was 
a  marked  improvement  in  the  condition  of  the  circu- 
lation. The  disappearance  of  cyanosis  was  one  of  the 
most  striking  features.  Burci  of  Florence  has  so  much 
faith  in  the  efficacy  of  this  mixture  that  prior  to  every 
operation  a  gasometer  containing  a  mixture  of  oxy- 
gen and  carbon  dioxid  is  prepared,  and  during  the 
operation  is  available  for  immediate  use  of  his  assist- 
ant administering  the  aniesthetic.  If  at  any  time  the 
patient  shows  evidences  of  the  slightest  tendency  to 
failure  of  respiratory  or  cardiac  functions,  he  admin- 
isters immediately  inhalations  of  this  gas  mixture  and 
does  not  wait  till  profound  shock  or  respiratory  paraly- 
sis is  reached.    A  rapid  return  of  normal  heart  action 


158  General  Anccsthetics  in.  Dentistry. 

and  breathing   is   the   almost   invariable   result.    The 

number  of  cases  thus  treated  during  the  past  two  years 
at  the  surgical  clinic  of  the  Florentine  university  now 
amounts  to  several  hundred.  In  no  case  has  any  ill  ef- 
fects been  observed  from  such  treatment.  In  several 
traumatic  cases  in  which  breathing  had  entirely  stop- 
ped, under  chloroform  anaesthesia,  a  prompt  return  to 
normal  breathing  occurred.  In  a  case  of  suicide  by 
hanging,  after  prolonged  artificial  respiration,  inhala- 
tions of  oxygen  and  hypodermic  stimulation  had  not 
given  the  slightest  results,  upon  administering  the  car- 
bon dioxid  mixture  after  a  few  inhalations  spontaneous 
respiration  returned. 

A  mixture  of  from  10-15  per  cent  of  carbon  dioxid 
after  the  completion  of  an  operation  is  very  effective  in 
causing  a  prompt  awakening  of  the  patient.  It  seems 
also  to  tend  to  decrease  post-chloroform  vomiting. 
This  is  probably  because  of  the  rapid  elimination  of 
chloroform  from  the  blood  and  tissues  under  the  influ- 
ence of  the  increased  respiration  induced  by  carbon 
dioxid.  (An  epitome  of  Levi's  paper  in  Journal  A.  M. 
A.,  March  16,  1912.) 

As  the  result  of  these  experiments  of  Yandell  Hen- 
derson and  others  the  entire  anaesthetic  procedure  now 
in  vogue  may  have  to  be  modified.  McKesson  of  To- 
ledo, and  others,  were  quick  to  recognize  the  impor- 
tance of  these  discoveries,  and  immediately  set  about 
to  construct  anaesthetic  appliances  by  which  carbon 
dioxid  could  be  used  in  connection  with  nitrous  oxid- 
oxygen   anaesthesia,   and   also  with   ether  and   chloro- 


General  Aiucsthetics  in  Dentistry.  159 

form.  A  re-breathing  chamber  or  compartment  is  ar- 
ranged, so  that  with  each  inhalation  of  nitrous  oxid, 
ether,  or  chloroform  a  percentage  of  carbon  dioxid  is 
admitted.  In  this  manner  the  patient  utilizes  his  own 
carbon  dioxid,  and  McKesson  further  shows  that  this 
re-breathing  procedure  results  in  an  actual  saving  of 
seventy-three  gallons  per  hour  of  nitrous  oxid,  and  be- 
sides makes  the  anaesthetic  safer.  It  would  seem  then, 
that  in  the  near  future,  especially  in  prolonged  anaes- 
thesias, the  re-breathing  method,  or  the  admixture  of 
carbon  dioxid  independent  of  what  is  exhaled,  will  re- 
ceive attention  and  be  utilized. 

Another  step  in  advance  has  been  scored  in  that  we 
not  only  have  a  safer  method  of  administering  anaes- 
thetics, but  have  gained  a  most  important  and  poten- 
tial therapeutic  agent  for  resuscitation  of  the  patient  in 
cases  of  impaired  respiration  and  circulation  during 
anaesthesia. 

It  occurs  to  me,  in  the  light  of  these  new  discov- 
eries, that  the  manufacturers  of  nitrous  oxid  and  oxy- 
gen should  also  prepare  for  our  use  cylinders  contain- 
ing 85%  of  oxygen  and  15%  of  carbon  dioxid,  and 
that  everybody  administering  either  local  or  general 
anaesthetics  procure  one  of  the  tanks  and  have  it  in 
readiness  in  case  it  was  needed. 

It  also  occurs  to  the  writer,  that  experiments  should 
be  made  with  this  combination  in  various  percentages 
and  results  carefully  studied.  If  it  can  be  shown  that 
such  a  combination  maintains  normal  respiration  and 
circulation  more  surely  than  oxygen  alone,  then  why 


160 


General  Anccsthetics  in  Dentistry. 


not  make  such  a  combination  as  a  substitute  for  pure 
oxygen  when  administering  nitrous  oxid  and  oxygen. 
Such  a  procedure  would  be  very  much  easier  and  far 
more  satisfactory  and  obviate  a  special  device  thus 
further  complicating  anaesthetic  appliances. 


THE    GWATHMEY    APPLIANCE. 


General  Anesthetics  in  Dentistry.  161 


LECTURE  XIII. 
Nitrous  Oxid  and  Oxygen  in  Operative  Dentistry. 

With  most  dentists,  the  word  anaesthesia  is  synony- 
mous with  extracting-  teeth.  Ask  the  average  dentist 
if  he  uses  general  anaesthetics  and  he  will  say,  "No,  I 
do  not  extract  more  than  three  or  four  teeth  a  month 
in  my  practice  and  have  no  use  for  anaesthetics."  If 
anaesthetics  meant  no  more  to  me  than  the  mere  ex- 
traction of  teeth,  I  would  not  have  prepared  these  lec- 
tures, I  can  assure  you.  The  dental  surgeon  should 
use  anaesthetics  in  all  painful  conditions.  One  of  our 
most  eminent  oral  surgeons,  Dr.  G.  V.  I.  Brown,  told 
me  recently,  that  if  he  should  resume  the  general  prac- 
tice of  dentistry  he  would  use  nitrous  oxid  a  thousand 
times  where  formerly  he  had  used  it  but  once.  The 
possibilities  of  this  anaesthetic,  especially  in  combina- 
tion with  oxygen,  had  not  been  realized  until  he  was 
called  upon  to  use  it  so  often  in  his  oral  surgery  prac- 
tice. 

In  what  class  of  cases  would  I  use  nitrous  oxid  and 
oxygen  ?  In  all  painful  conditions  the  dentist  is  called 
upon  to  treat :  Sensitive  cavity  preparation  ;  removal  of 
pulps  surgically,  and  sometimes  after  an  arsenical  ap- 
plication has  been  made ;  shaping  teeth  for  crowns  or 
abutments    whether    alive    or    devitalized,    for   in   one 


162  General  Anccsthetics  in  Dentistry. 

instance  they  are  exquisitely  sensitive,  in  the  other 
the  grinding  and  cutting  is  more  wearing  on  some 
patients  than  a  real  "hurt" ;  adjusting  cervical  or  pain- 
ful clamps;  treating  pyorrhoea;  rapid  wedging  of  the 
teeth  to  gain  space  for  filling ;  opening  into  teeth  af- 
fected with  pericementitis  or  acute  alveolar  abscess ; 
lancing  abscesses;  opening  into  pulps  for  the  purpose 


THE   TETEE   NASAL  INHALER. 


of  making  an  arsenical  treatment — in  short,  all  pain- 
ful or  fatiguing  operations  on  the  teeth.  Once  familiar 
with  operating  under  analgesia  or  anaesthesia  you 
would  relinquish  dentistry  rather  than  practice  as  you 
are  now  doing.  You  may  think  you  know,  but  you  do 
not  know  the  first  letter  in  the  word  "gratitude,"  nor 
will  you  know  till  you  have  looked  into  the  eyes  and 
faces  of  yonr  patients  wlien  they  leave  the  chair  after 
using  nitrous  oxid  and  oxygen. 


General  Ancesthetics  in  Dentistrv. 


163 


The  most  sensitive  cavities  can  be  prepared,  the 
most  painful  conditions  rendered  absolutely  painless 
by  this  method.  It  is  seldom  necessary  for  the  patient 
to  lose  consciousness;  it  is  a  stage  of  analgesia  rather 


THE  TETEK  1-Mi'l^OVED  APPAKATUS  XO    ^ 
WITH  VAPOR  WABMER  AND  STAND.       ' 

than  anaesthesia,  the  patients  once  in  a  while  momen- 
tarily passing  into  unconsciousness. 

Have  the    patient  understand  he  is  not  to  be  hurt, 
that  the    whole  matter  is, under  his  control.   Adjust  the 


164  General  Ancusthetics  in  Dentistry. 

rubber  dam,  insert  the  mouth-prop,  apply  the  nasal 
inhaler,  as  explained  in  the  last  lecture.  Instruct  the 
patient  to  raise  the  hand  if  he  feels  pain ;  keep  up  a 
running  conversation  with  the  patient  like  this :  "Am 
I  hurting  you  ?    Do  you  feel  pain  ?   Do  you  mind  what 


The  Orefrg  inhaler  consists  of  a  steel  bow,  padded  at  each  end, 
extending  from  the  forehead  to  the  bnse  of  the  skull. 

This  bow  supports  the  tubing  and  exhalation  valve  by  means 
of  two  small  spring  clips.  The  tubing  extends  from  the  nares 
back  over  the  head  to  the  gas  apparatus.  In  order  to  adjust  the 
appliance  simply  place  bow  on  the  head  by  opening  it,  according 
to  size  of  head,  pull  tubing  forward  through  spring  clip  so  as  to 
bring  it  firmly  into  the  nares. 

The  advantages  of  the  inhaler  are: 

Its  quick  adjustment,  about  ten  seconds  or  less,  and  perfect 
comfort  when  in  ])osition. 

It  does  not  interfere  with  o))erationH  in  the  mouth. 

Does  not  depress  the  upper  lip. 

Does  not  suggest  smothering  by  covering  the  nose,  and  is  very 
easily  kept  clean, 


General  Ancesthetics  in  Dentistry.  165 

I  am  doing?  Are  you  asleep?"  etc.,  etc.  You  can 
keep  patients  in  this  condition  indefinitely,  and  they 
will  be  resuscitated  in  two  minutes  after  discontinuing 
the  angeestlietic  and  leave  the  office  buoyant  and  happy, 
not  dreading  to  return  for  the  next  appointment.  And 
the  operator — that  all-gone,  all-used-up,  collapsed  feel- 
ing, that  five  o'clock  feeling,  is  gone  to  return  no  more. 

The  rubber  dam  adjusted,  you  need  only  the  nasal 
inhaler.  Instruct  the  patient  to  breathe  rather  deeply 
the  first  four  or  five  inhalations,  then  assume  natural 
breathing.  Begin  by  breaking  down  enamel  walls  with 
a  chisel  or  proceed  gently  with  a  bur,  the  hand  to  be 
raised  if  pain  is  felt,  if  the  operation  is  the  preparation 
of  a  carious  tooth.  If  the  patient's  face  shows  the 
slightest  cyanosis,  indicate  oxygen,  and  have  the  as- 
sistant admit  a  little  more  oxygen  ;  this  is  usually  suf- 
ficient, but  varies  with  the  individual.  Maintain  this  a 
while  if  the  patient  does  not  become  cyanotic  again. 
If  the  patient  shows  a  tendency  to  laugh,  or  manifests 
signs  of  stimulation,  diminish  or  discontinue  the  oxy- 
gen. It  is  simply  a  matter  now  of  administering  just 
enough  of  the  combination  to  get  results.  If  you 
find  the  patient  going  down  too  deeply,  discontinue 
or  diminish  the  anaesthetic  for  a  few  inhalations. 
You  will  soon  learn  the  stage  in  which  to  operate,  by 
practice. 

All  that  has  been  said  about  preparation  of  the  pa- 
tient is  applicable  here.  A  light  breakfast  or  a  light 
lunch  must  be  insisted  upon.  Loosen  all  bands,  have 
the  corset  removed,  and  the  bladder  should  be  empty. 
When  you  know  in  advance  that  you  are  to  operate 


166 


General  Anccsthctics  in  Dentistry. 


ANESTHETIC  INDUCTION. 

THE  DeFOKD  NITEOUS  OXID  AND  OXYGEN  INHALEE- 

NASAL. 


This  inhaler  is  unique  in  that  it  provides  a  mouth  cover  which 
excludes  the  entrance  of  air  through  the  mouth  while  patient  is 
being  anajsthetized.  When  patient  is  ready  for  the  operation  the 
mouth  cover  is  everted  and  held  up  out  of  the  way.  All  during 
the  o))eration  the  patient  inhales  through  the  nose,  and  if  signs 
of  resuscitation  are  noticed  before  the  completion  of  the  opera- 
tion, the  mouth  cover  is  dropped  to  its  position  over  the  mouth, 
and  surgical  ana-sthesia  is  quickly  induced  again.  This  inhaler  is 
intended  to  be  used  with  any  nitrous  oxid  appliance. 


General  .liucstliefics  in  Dentistry.  167 

under  aiuesthcsia,  tlic  patient  can  l)e  instructed  in  re- 
gard to  loose  clothing-  and  dress  accordingly.  Those 
who  do  not  insist  on  these  precautions  never  attain 
the  same  degree  of  success. 

An  anaesthetic  clinic  is  the  most  difficult  of  all  clin- 
ics in  which  to  get  satisfactory  results,  and  those  who 
see  anaesthetics  administered  at  clinics  only,  have  little 
appreciation  of  what  can  be  accomplished  in  the  quiet 
of  an  office  with  proper  surroundings.  Everything 
depends  upon  the  tranquillity  of  mind  that  can  be  in- 
duced, and  there  is  little  chance  for  this  in  a  public 
clinic.  If  the  patient  is  a  woman,  the  possibilities  of 
saying  or  doing  something  improper  tends  to  excite- 
ment and  restlessness  of  mind  rather  than  quiet  and 
composure. 

One  of  the  most  successful  public  anaesthetic 
demonstrations  I  have  ever  witnessed  was  conducted 
by  Dr.  Jessie  Ritchey  DeFord,  of  Des  JMoines,  at  the 
Fourth  Annual  Alumni  Clinic  of  the  College  of  Den- 
tistry, State  University  of  Iowa,  Iowa  City,  February 
4th,  1907.  The  operator  had  never  operated  upon 
teeth  before  under  anaesthesia.  His  clinic  was  to  make 
a  porcelain  inlay  in  an  upper  right  cuspid  labial  sur- 
face, gingival  cavity.  Indeed,  this  was  his  first  ap- 
pearance as  a  clinician.  The  tooth  was  so  sensitive 
that  the  patient  could  not  stand  even  drying  it  with 
absorbent  cotton.  lie  objected  to  taking  nitrous  oxid 
and  oxygen  because,  on  a  previous  occasion,  he  was 
made  very  sick  from  ether.  He  had  three  or  four  other 
cervical  cavities  and  finally  consented  to  take  the  anaes- 
thetic under  two  conditions.     The  first  was  that  the 


168  General  Ancrsthetics  in  Dentistry. 

preparation  of  the  cavity  should  be  painless,  and,  sec- 
ond, that  all  the  cavities  should  be  prepared  for  fillings 
if  he  found  he  was  not  being  hurt.  The  doctor  pro- 
ceeded with  the  anaesthetic  as  I  have  described,  and  the 
patient,  a  dental  student,  at  no  time  lost  consciousness, 
and  when  the  first  cavity  preparation  was  completed 
said,  "Go  on  with  the  next  one,  I  am  not  being  hurt,  I 
am  having  the  time  of  my  life,"  and  during  the  twenty- 
five  minutes  consumed  in  cavity  preparation,  he  never 
once  raised  his  hand  to  indicate  he  was  feeling  pain, 
and  said  a  dozen  times,  "I  am  not  minding  it,  there  is 
no  pain,  go  ahead."  He  made  this  request,  however, 
"My  throat  is  getting  cold,  please  add  more  warm 
water."  Here  was  a  patient  that  had  no  confidence  in 
the  anaesthetic  for  such  operations,  and  an  operator 
who  was  naturally  embarrassed  and  timid,  having 
never  before  operated  under  an  anaesthetic,  or  even  at 
a  clinic,  yet  the  result  was,  as  I  have  described  it,  and 
you  can  hardly  imagine  a  more  trying  ordeal  for  the 
anaesthetist.  The  same  anaesthetist  later  in  the  day  in- 
duced a  thirty-minute  anaesthesia  at  the  University 
Hospital  with  nitrous  oxid  and  oxygen  for  an  opera- 
tion on  the  soft  palate  performed  by  Dr.  G.  V.  I. 
Brown. 


General  Anccstlictics  in  Dentistry.  169 


LECTURE  XIV. 
Ethyl  Chloride. 

Physicians  have  long  sought  an  anaesthetic  agent 
as  quick  in  its  action  as  nitrous  oxid,  as  free  from 
danger  as  nitrous  oxid,  with  as  little  after  disturbance, 
yet  one  with  which  a  longer  period  of  anaesthesia  could 
be  obtained  without  the  cumbersome  apparatus  inci- 
dent to  nitrous  oxid  narcosis. 

Ethyl  chloride  when  first  introduced  was  supposed 
to  be  the  long-waited-for  agent  so  devoutly  desired. 
This  anaesthetic  was  first  used  by  Heyfelder,  in  1848. 
In  1880,  a  committee  of  the  British  Medical  Associa- 
tion after  experimenting  on  animals,  rendered  an  ad- 
verse report,  and  its  use  was  abandoned.  In  the  year 
1895,  Carson  and  Thiesing  revived  ethyl  chloride  and 
it  was  used  to  some  extent  by  dentists.  This  same 
year  Soullier,  of  Lyons,  reported  its  use  in  8,417  clini- 
cal cases  without  a  fatality.  The  first  real  scientific 
work,  however,  is  said  to  have  been  done  by  Lotheisen 
and  Ludwig  in  Prof,  von  Hacker's  clinic  in  1897-98. 

McCardie,  in  1902-03,  studied  the  value  of  this  drug 
in  620  general  narcoses  and  was  enthusiastic  in  his 
praise  of  this  agent,  claiming  that  it  contains  all  the 
requisites  of  a  perfect  anaesthetic ;  and  these  we  find 
set  forth  bv  Tuttle  as : 


170  General  Ancesthetics  in  Dentistry. 

1.  Safety. 

2.  Insensibility  to  pain. 

3.  Complete  relaxation. 

4.  Easy  and  rapid  production  of  effect. 

5.  Freedom  from  dangers  and  disagreeable  after- 
effects. 

6.  Simplicity  of  administration. 

Tiittle  believes,  too,  that  these  requisites  are  nearly 
all  inherent  in  ethyl  chloride.  (Montgomery  and 
Bland  in  Jour.  A.  M.  A.,  April  2,  1904.)  Chemically, 
ethyl  chloride  is  one  of  the  haloid  substitutions  derived 
from  ethyl  alcohol,  and  it  is  formed  by  the  halogen 
element,  chlorine,  replacing  the  hydroxyl  group  in  the 
alcohol. 

Those  who  claim  that  the  heart's  action  in  the  be- 
ginning is  increased  are  in  the  majority.  These,  how- 
ever, admit  that  the  circulation  returns  to  normal  as 
soon  as  anaesthesia  is  induced,  and  that  this  primary 
disturbance  is  due  to  nervous  excitement  rather  than 
direct  influence  of  the  drug,  an  experience  common  to 
the  administration  of  any  ansesthetic.  While  some 
have  sought  to  show  that  arterial  tension  is  increased, 
others  are  as  positive  that  arterial  tension  is  dimin- 
ished. I  think  this  difference  of  opinion  has  arisen  be- 
cause some  investigators  have  experimented  during  a 
light  anaesthesia,  while  other  observers  have  made  their 
observations  during  deep  anaesthesia.  Wood  found 
that  upon  anaesthetizing  animals  to  a  deep  narcosis 
the  arterial  tension  was  lowered,  but,  when  the  anaes- 
thetic was  discontinued,  the  arterial  tension  regained 


General  AiicFsthetics  in  Dentistry.  171 

the  normal ;  so  it  is  possible  that  in  some  of  the  experi- 
ments that  have  been  reported  that  the  narcosis  was 
not  deep  enough  to  lower  arterial  tension. 

Koenig  not  only  believes  that  the  arterial  tension  is 
lowered  in  deep  ethyl  chloride  anaesthesia,  but  says  it 
is  due  to  the  influence  of  the  agent  on  the  pneumogas- 
tric,  because  it  disappeared  after  the  vagi  were  cut  in 
animals. 

Malherbe  and  Roubinovich  made  a  test  of  twenty- 
four  cases  with  Potain's  sph}gmomanometer  to  ascer- 
tain the  action  of  ethyl  chloride  on  arterial  pressure  in 
man.  "Of  the  twenty-four  cases  examined  by  Mal- 
herbe and  Roubinovich,  arterial  tension  was  decreased 
in  twenty-two,  and  the  frequency  of  the  pulse-beats 
followed  equally  the  modifications  in  the  degree  of 
arterial  pressure  ;  during  deep  sleep  diminishing  and 
increasing  and  attaining  finally  the  normal  number 
as  consciousness  was  restored." 

McCardie  concludes  that  the  pulse  is  slower  than 
normal  in  deep  amesthesia,  but  that  its  regularity  is 
maintained. 

Montgomery  and  Bland  found  that  in  patients  with 
a  normal  circulatory  apparatus  there  was  usually  a 
slight  decrease  in  arterial  tension.  There  was  no  de- 
cided disturbance  in  the  pulse-beat.  At  the  beginning 
of  the  administration,  however,  there -was  a  certain  in- 
crease in  the  frequency  of  the  j^ulsations,  but  this,  of 
course,  was  due  to  the  psychic  disturbance  of  the  pa- 
tient, and  not  from  any  direct  action  of  the  drug.  The 
respirations  were  generally  stimulated  both  in  fre- 
(juency  and  depth. 


172  General  Ancesthetics  in  Dentistry. 

There  is  little  if  any  irritation  to  the  respiratory 
mucous  membrane  and  this  is  a  point  well  worth 
remembering,  as  collection  of  mucus  in  the  pharynx 
under  ether  anaesthesia  sometimes  almost  defeats  suc- 
cessful operating.  Another  feature  worthy  of  men- 
tioning is  that  the  tongue  does  not  swell  or  increase 
in  size  under  ethyl  chloride  anaesthesia  as  it  does  under 
nitrous  oxid  narcosis. 

Unfortunately  eth}^  chloride  narcosis  is  followed 
frequently  by  nausea,  and  but  for  this  disturbing  ele- 
ment would  be  far  more  popular  and  even  more  ex- 
tensively used  than  at  present. 

Headache  is  more  commonly  experienced  after  an 
administration  of  ethyl  chloride  than  after  an  adminis- 
tration of  nitrous  oxid  gas.  Another  thing  to  be  re- 
membered is  that  according  to  Luke,  ethyl  chloride 
has  an  affinity  for  the  masseter  muscle  and  the  spasm 
is  sometimes  so  severe  that  it  is  difficult  to  find  a 
mouth-prop  that  will  withstand  the  strain. 

*       Safety. 

I  consider  ethyl  chloride,  in  careful  hands,  one  of 
the  safest  of  anaesthetics.  It,  of  course,  has  its  limita- 
tions, and  I  think  nearly  all  mortalities  reported  as  re- 
sult of  using  this  anaesthetic  have  been  due  to  care- 
lessness, improper  administration,  or  attempting  too 
prolonged  an  anaesthesia.  Most  of  the  mortalities  re- 
ported have  occurred  abroad,  and  you  must  take  into 
consideration  that  "abroad"  means  usually  that  the 
"closed"  method  has  been  employed,  air  excluded. 

Soullier  and  Lyons  report  8,417  cases  without  an 


General  Anccsthctics  in  Dentistry.  173 

adverse  symptom.     Seitz  rei)orts  but  one  death  in  16,- 

000  cases  collected  by  him,  and  this  death  occurred  in 
a  case  in  which  ethyl  chloride  was  contra-indicated. 
Ware  reports  one  death  in  8,207  cases,  and  the  death 
was  probably  the  same  one  reported  by  Seitz.  Mc- 
Cardie  asserted  "that  it  was  the  safest  of  all  anaesthet- 
ics except  nitrous  oxid,  and  that  the  death  rate  might 
be  placed  at  one  in  many  hundred  thousand."  He  has 
since  somewhat  modified  his  views,  but  as  late  as 
March  17th,  1906,  in  The  British  Medical  Journal,  says: 
"Fortunately,  in  an  experience  of  nearly  2,000  cases 

1  have  not  seen  either  asphyxia  or  syncope  during  its 
administration."  Again,  he  says:  "Since  1897,  ethyl 
chloride  has  been  very  rapidly  growing  in  popularity, 
so  much  so,  indeed,  that  it  has,  unfortunately,  largely, 
and  in  some  places  altogether  replaced  nitrous  oxid. 
For  instance,  in  the  General  Hospital,  Birmingham, 
the  latter  is  rarely  used  at  all  save  in  the  dental  depart- 
ment. The  reasons  for  this  popularity  are  those  that 
make  chloroform  so  favored  :  ethyl  chloride  is  rather 
pleasant  to  inhale,  is  non-irritating  to  the  air-passages, 
and,  more  than  all,  it  is  most  pleasant  and  easy  to  ad- 
minister." 

Weissner  states  that  in  Von  Hacker's  clinic  in 
Innsbruck,  that  ethyl  chloride  is  used  when  ether  and 
chloroform  are  contra-indicated  in  high  degrees  of  cir- 
culatory interruption,  fatty  degeneration  of  the  heart, 
diseases  of  the  respiratory  organs,  persons  enfeebled 
by  great  loss  of  blood  and  those  suffering  from  nerve 
shock. 

Luke,  of  Edinburgh,  in  his  "Guide  to  Anaesthetics" 


174  General  Aiucsthetics  in  Dentistry. 

says:  "In  the  past  two  years  ethyl  chloride  has  made 
enormous  strides  in  this  country  and  bids  fair  to  be  the 
most  frequently  employed  anaesthetic  which  we  possess. 
It  has  almost  completely  displaced  nitrous  oxid  in  gen- 
eral surgery." 

Luke  places  the  death  rate  at  one  in  12,000.  Lothei- 
son  thought  ethyl  chloride  to  be  "quite  harmless,"  and 
in  April,  1902,  reckoned  the  mortality  to  be  one  in 
17,000. 

Administration. 

Ethyl  chloride  may  be  obtained  in  capsules  and  in 
tubes.  The  tubes  usually  contain  about  sixty  cubic 
centimeters,  but  the  quantity  varies  with  different 
manufacturers,  and  some  manufacturers  make  two  or 
more  sizes.  The  larger  tubes  are  fitted  with  a  spray 
attachment.  These  tubes,  some  of  them  at  least,  are 
graduated  so  that  the  amount  of  material  being  used 
for  anaesthetic  purposes  can  be  seen.  For  the  purposes 
of  general  anaesthesia,  the  ethyl  chloride  is  sprayed 
from  these  tubes  into  an  inhaler.  The  capsules  are 
made  of  glass  and  usually  contain  from  three  to  five 
cubic  centimeters  hermetically  sealed. 

There  are  a  number  of  inhalers  on  the  market  and 
these  are  so  arranged  that  ethyl  chloride  can  either  be 
sprayed  into  the  inhaler  or  one  of  the  capsules  frac- 
tured and  its  contents  discharged  upon  a  piece  of  gauze 
arranged  for  that  purpose.  An  ethyl  chloride  in- 
haler may  be  improvised  by  modifying  somewhat 
an  Esmarch  chloroform  inhaler.  The  Esmarch  in- 
haler,  as   you   will    recall,  consists   of   a   wire   frame 


General  AnccstJictics  in  Dentistry.  175 

over  which  is  stretched  a  piece  of  stockinet  or 
surgeon's  gauze,  which  extends  over  the  edges  and 
is  clamped  down.  Over  this  surgeon's  gauze  is 
stretched  a  piece  of  rubber  dam.  Clamp  the  rubber 
dam  down  with  the  gauze,  and  from  time  to  time  spray 
a  small  quantity  of  ethyl  chloride  on  the  gauze  lift- 
ing it  away  from  the  face  just  as  the  patient  completes 
an  inhalation.  This  can  be  accomplished  while  the  pa- 
tient is  exhaling,  and  does  not  interfere  seriously  with 
the  administration.  It  takes  longer  to  anaesthetize  a 
patient  and  more  material  is  used  than  when  employ- 
ing one  of  the  many  inhalers  supplied  by  the  dental 
and  surgical  dealers. 

Both  the  Stark  and  DeFord  somnoform  inhalers 
are  excellent  ethyl  chloride  inhalers.  As  these  ap- 
pliances and  their  use  are  described  in  the  somnoform 
lecture,  it  will  not  be  necessary  to  refer  to  them  in  this 
lecture  except  by  name. 

In  the  administration  of  ethyl  chloride  we  have  the 
choice  of  two  methods ;  namely,  first,  in  which  all  air 
is  excluded,  and  second,  in  which  various  amounts  of 
atmospheric  air  is  admitted  to  the  lungs  along  with  the 
ethyl  chloride. 

With  breathing  a  little  deeper  than  normal,  in 
twenty  to  thirty  seconds  light  anaesthesia  is  induced. 
If  the  patient  is  large  and  muscular,-  after  four  or  five 
inhalations  it  is  sometimes  necessary  to  add  ain^ther 
c.  c.  At  that  point  where  consciousness  is  lost,  "the 
patient  often  quits  breathing  for  from  five  to  twenty 
seconds."  About  this  time,  the  patient  may  become 
stimulated  or  excited,  move  the  feet  and  erab  at  the 


176  General  Anccsthetics  in  Dentistry. 

bag.  Then  consciousness  is  lost,  the  pupil  dilates,  the 
eyeballs  roll,  and  the  respiration  becomes  deeper  and 
slower.  At  this  stage,  two  or  three  teeth  may  be  ex- 
tracted and  the  patient  not  feel  the  pain ;  affording  a 
working  period  from  twenty  to  forty  seconds.  If  there 
is  sufficient  anaesthetic  in  the  bag,  and  the  patient  is 
permitted  to  breathe  about  ten  seconds  longer,  we  get 
a  very  profound  anaesthesia  which  will  last  from  one 
hundred  to  one  hundred  and  twenty  seconds.  At  this 
time,  the  corneal  reflex  is  abolished,  the  face  reddens 
slightly  and  sometimes  perspiration  appears  on  the 
face.  If  the  anaesthetic  is  discontinued  at  the  end  of 
the  first  stage,  the  patient  awakes  suddenly  like  one 
coming  out  of  a  hypnotic  sleep.  In  the  deeper  anaes- 
thesia just  described,  most  patients  recover  quickly, 
but  there  is  with  all  a  dreamy  or  drowsy  stage  just 
before  awaking,  and  after  awaking,  with  many,  they 
close  their  eyes  again  for  a  secondary  nap  of  a  few 
seconds.  Just  before  awaking  is  the  time  when  neuro- 
tic women  and  alcoholics  make  trouble,  if  they  are  to 
become  excited  after  the  operation.  It  is  a  dangerous 
procedure  to  try  to  forcibly  restrain  either  class  men- 
tioned. Neurotics  and  alcoholics  occasionally  become 
excited  going  under,  but  ordinarily  it  is  just  before 
awaking,  if  they  make  trouble  at  all,  that  you  must  be 
on  your  guard.  Do  not  try  to  restrain  them  and  you 
will  seldom  have  trouble. 

Cyanosis  is  a  rare  condition  during  ethyl  chloride 
anaesthesia,  and  if  it  should  be  present,  it  arises  not 
frgm  the  ethyl  chloride  itself,  but  rather  from  some 


General  Aiurstlietics  in  Dentistry.  177 

mechanical  interference  of  the  respiration,  as  swalknv- 
ing  the  tongue. 

In  the  stage  of  Hght  anaesthesia,  there  are  seldom 
any  unpleasant  or  disagreeable  after-effects.  The  pa- 
tient is  awake  and  entirely  himself  in  about  a  minute 
from  the  time  the  first  inhalation  is  taken. 

Following  the  second  condition  described,  in  which 
the  anaesthesia  induced  was  of  a  very  profound  nature, 
tiausea  and  headache  are  sometimes  present.  I  am  in- 
clined to  the  view  that  nausea  and  headache  following 
the  administration  of  ethyl  chloride,  when  the  "close 
method"  is  employed,  are  caused  not  so  much  from  the 
ethyl  chloride  itself,  but  is  rather  tlie  result  of  re-inhal- 
ing the  contents  of  the  rubber  bag. 

I  dare  say  if  any  inhaler  be  used  in  exactly  the 
same  manner  and  be  held  the  same  length  of  time 
over  the  nose  and  mouth,  and  a  given  num1)er  of  pa- 
tients inhale  and  rc-inhale  the  contents  of  the  bag, 
without  ethyl  chloride  being  added,  a  certain  number 
of  those  trying  the  experiment  will  experience  nausea 
and  headache.  Blood  entering  the  stomach  nearly  al- 
ways produces  nausea.  The  anaesthetic  should  not  be 
held  responsible  for  nausea,  the  result  of  swallowed 
blood. 

The  Stark  and  DeFord  inhalers  are  so  arranged 
that  the  amount  of  anresthetic  and  .the  amount  of  air 
entering  the  lungs  can  be  very  accurately  gauged.  I 
am  an  advocate  of  the  open  method  in  administering 
ethyl  chloride,  just  as  T  prefer  the  admission  of  air 
freely  in  the  administration  of  ether,  chloroform  and 
somnoform.    Take  a  3  c.  c.  capsule  of  ethyl  chloride, 


178  General  Anccsthetics  in  Dentistry. 

place  it  ill  its  compartment  in  the  Stark  or  DeFord 
inhaler,  with  the  appliance  in  position,  and  the  patient 
ready,  fracture  the  tube.  For  the  first  two  or  three 
inhalations,  admit  all  air,  then  just  a  little  ethyl 
chloride,  then  a  little  more,  then  a  little  more.  Now 
all  air  may  be  excluded  and  the  patient  permitted  to 
breathe  once  or  twice  and  usually  an  available  anaes- 
thesia of  about  ninety  seconds  can  be  obtained.  You 
can  regulate  the  depth  of  the  anassthesia  to  suit  the 
operation  to  be  performed.  Nausea  and  headache  fol- 
lowing the  administration  of  ethyl  chloride  with  an 
admixture  of  air  is  less  frequent  than  when  all  air  is 
excluded.  As  ethyl  chloride  is  administered  in  the 
same  kind  of  an  appliance  as  somnoform  and  both 
preparations  are  sold  in  the  same  kind  of  containers 
and  in  the  same-sized  tubes  and  capsules,  the  reader, 
for  a  more  minute  description  of  the  administration  of 
ethyl  chloride,  is  referred  to  the  lecture  on  administra- 
tion of  somnoform. 

As  the  difficulties  and  dangers  encountered  in  ethyl 
chloride  administration  are  also  the  same  as  those  aris- 
ing from  somnoform  anzesthesia,  these  will  be  found  to 
be  very  fully  discussed  in  the  somnoform  lectures. 


General  AtKcstlictics  in  Dentistry.  179 


LECTURE  XV. 
Somnoform. 

We  are  indebted  to  Dr.  G.  Rolland,  of  Bordeaux, 
France,  for  the  ancesthetic  mixture  which  he  has  named 
somnoform.  In  1895,  Dr.  Rolland  organized  the  Bor- 
deaux Dental  School,  and  to  him  was  assigned  the 
chair  of  anaesthesia.  Not  being  satisfied  with  the 
anaesthetics  in  general  use  for  dental  purposes,  he  ex- 
perimented with  various  anaesthetic  mixtures  till  1899, 
when  he  made  public  the  results  of  his  research.  He 
maintained  that  an  ideal  anaesthetic  should  be  one  that 
"would  enter  into,  sojourn  in,  and  make  its  exit  from 
the  organism  in  the  same  manner  that  oxygen  does; 
that  the  tension  of  the  anaesthetic  agent  should  be 
greater  than  that  of  oxygen  in  order  that  it  might 
take  the  place  of  oxygen  in  the  lung  alveoli ;  and  that, 
according  to  the  laws  of  the  physiology  of  respiration, 
tension  produces  two  classes  of  phenomena  which  al- 
ternate and  are  opposed  to  each  other,  namely,  absorp- 
tion and  elimination,  and,  as  the  degree  of  volatility  of 
a  gas  determines  its  pressure,  the  more  volatile  a  gas, 
the  more  easily  it  can  be  absorbed,  and  consequently 
the  more  easily  it  can  be  made  to  take  the  place  of 
oxygen." 

Just  as  the  red  blood  corpuscles  are  charged  with 
'oxygen, during  inhalation  and  distributed  to  the  tissues. 


180  General  Ancesthetics  in  Dentistry. 

so  will  somnoform  be  absorbed.  It  is  estimated  that  it 
takes  about  thirty  seconds  from  the  time  the  blood 
leaves  the  lungs  charged  with  oxygen  until  it  returns 
laden  with  carbon  dioxide.  A  given  red  corpuscle, 
then,  would  have  fed  out  all  of  its  oxygen  in  about 
fifteen  seconds.  Rolland  argued  that,  as  the  oxygen 
of  the  blood  is  consumed  in  about  fifteen  seconds,  the 
ideal  anaesthetic  should  be  as  rapid  in  its  action,  and 
experimented  along  that  line. 

In  the  chloride  of  ethyl,  we  have  an  anaesthetic 
agent  almost  as  rapid  in  its  action  as  somnoform,  but 
no  doubt  Rolland  satisfied  himself  that  this  agent  was 
not  volatile  enough  and  had  too  high  a  death  rate. 
Bromide  of  ethyl  evidently  did  not  meet  his  approval. 
This  latter  agent  is  not  as  volatile  even  as  the  ethyl 
chloride.  Methyl  chloride  is  more  volatile  than  either 
of  these  agents  and  no  doubt  is  added  to  the  ethyl 
chloride  and  the  ethyl  bromide  on  account  of  its  rapid 
evaporation,  thus  increasing  the  tension  of  somnoform 
and  causing  it  to  be  more  rapidly  absorbed  and  more 
quickly  eliminated.  It  is  said  that  methyl  chloride 
volatizes  at  twenty  degrees  below  zero,  and  it  is  this 
agent  that  makes  somnoform  so  volatile. 

Somnoform  is  composed  of 

Old  Formula.  New  Formula. 
Ethyl  Chloride                 60%  83% 

Methyl  Chloride  35%  16% 

Ethyl  Bromide  5%  1% 

I  am  inclined  to  think  that  this  is  a  raechanicat 


General  Aiucstlwtics  in  Dentistry.  181 

mixture  rather  than  a  chemical  compound.  Ijv  exclud- 
ing all  air,  anaesthesia  can  be  induced  in  about  fifteen 
seconds.  I  believe  this  to  be  due  to  the  difTusibility 
of  the  meth}d  chloride.  The  mcth}^  chloride  possesses 
anaesthetic  properties  of  its  own,  and  of  the  three 
agents  would  naturally  evaporate  quicker  than  the 
others,  carrying  some  of  their  vapor  along  with  it.  In 
the  matter  of  volatility,  the  ethyl  chloride  comes  next, 
and  serves  to  prolong  the  amesthesia,  and  the  ethyl 
bromide  would  naturally  evaporate  more  slowdy  than 
the  others,  maintaining  the  anaesthesia  as  the  other 
agents  would  be  more  rapidly  eliminated. 

We  know  that  with  nitrous  oxid  the  average  induc- 
tion period  is  forty-four  seconds,  and  the  average  avail- 
able period  of  anaesthesia  is  thirty  seconds,  while 
with  somnoform,  when  all  air  is  excluded,  the  induc- 
tion period  is  from  fifteen  to  thirty  seconds,  and  the 
period  of  available  anaesthesia  from  sixty  to  three  hun- 
dred seconds. 

I  have  noticed  in  using  the  large  somnoform  tubes 
that  after  two  or  three  anaesthesias  have  been  induced 
the  bromide  odor  becomes  more  pronounced,  and  when 
nearly  empt}-  the  odor  is  aluKxst  that  of  pure  ethyl 
bromide,  and  it  is  from  this  fact  that  I  have  come  to 
believe  that  somnoform  is  not  a  chemical  compound, 
but  a  mechanical  mixture,  and  that  each  ingredient  is 
inhaled  in  proportion  to  its  volatility.  I  do  not  mean 
by  this  that  the  patient  gets  at  first  all  or  nothing  but 
methyl  chloride,  then  the  ethyl  chloride,  and  after 
these  the  ethyl  bromide,  because  the  methyl  chloride 
no  doubt  carries  some  of  the  va])or  of  both  of  these 


182  General  Ancesthetics  in  Dentistry. 

agents  along  with  it ;  but  I  do  believe  that  in  a  general 
way,  with  somnoform,  we  get  an  anaesthesia  character- 
istic of  each  agent  in  a  modified  form.  For  instance, 
there  is  less  muscular  spasm  during  somnoform  anaes- 
thesia than  in  the  anaesthesia  induced  by  ethyl  chloride ; 
there  is  less  nausea  following  somnoform  anaesthesia 
than  with  ethyl  chloride  or  ethyl  bromide  alone ;  som- 
noform anaesthesia  is  more  tranquil  than  ethyl  chlo- 
ride anaesthesia,  somnoform  anaesthesia  is  superior  in 
every  respect  to  the  anaesthesia  induced  by  either  ethyl 
bromide  or  ethyl  chloride. 

As  to  safety,  somnoform  outclasses  both  ethyl 
chloride  and  ethyl  bromide,  and  it  is  difficult  to  explain 
why  there  should  be  such  a  discrepancy  in  the  mor- 
talities incident  to  these  anaesthetics.  Ethyl  chloride 
and  ethyl  bromide  are  administered  almost  universally 
by  physicians  and  professional  anaesthetists,  the  patient 
having  been  prepared  in  advance ;  while  somnoform 
has  been  administered  mostly  by  dentists,  many  of 
them  purchasing  appliances  and  administering  it  with- 
out any  experience  whatever.  Dental  salesmen  were 
sent  out  from  almost  every  dental  depot  in  the  United 
States,  and  actually  instructed  dentists  in  the  use  of 
somnoform  ;  many  of  these  salesmen,  prior  to  this,  had 
never  seen  an  anaesthetic  administered ;  yet,  when  you 
compare  the  death  rate  of  these  anaesthetics,  two  being 
administered  almost  entirely  by  physicians  and  pro- 
fessional anaesthetists,  and  the  other  by  inexperienced 
dentists  and  traveling  salesmen,  the  results  obtained 
are  almost  beyond  belief.  The  death  rate  of  ethyl 
chloride  is  estimated  at  about  one  in  twelve  thousand. 


General  Aiiastlietics  in  Dentistry.  183 

The  death  rate  of  ethyl  bromide  is  one  in  about  five 
thousand  administrations.  Combining  these  two  anaes- 
thetics with  nictliyl  chloride  in  the  proportions  men- 
tioned we  have  soninoform,  with  a  mortality  of  about 
six  in  two  million  administrations. 

It  might  almost  seem  that  I  must  be  mistaken  in 
saying-  that  somnoform  is  a  mechanical  mixture,  but 
rather  that  it  is  a  chemical  compound,  the  safety  of 
which  is  infinitely  greater  than  the  safety  of  its  con- 
stituent parts.  I  have  been  asked  hundreds  of  times  if 
I  considered  somnoform  as  safe  as  nitrous  oxid  gas. 
This  is  rather  a  difficult  question  to  answer.  The  an- 
swer can  not  be  gi\en  "yes"  or  "no"  without  going 
somewhat  into  details.  If  all  air  is  excluded  in  admin- 
istering nitrous  oxid  gas,  Hewitt  says,  the  average  time 
in  which  dangerous  asphyxia  is  produced  is  fifty-six 
seconds.  This,  he  also  says,  is  the  average  time  of  com- 
plete anaesthesia.  It  is  not  true  of  any  other  anaes- 
thetic with  which  I  am  accpiainted,  that  the  stage  of 
surgical  anaesthesia  and  the  danger  point  is  the  same. 
We  are  always  in  danger,  then,  with  nitrous  oxid, 
according  to  Hewitt,  when  the  patient  is  surgically 
anaesthetized.  But,  before  we  reach  this  point  with 
nitrous  oxid,  the  distress  of  the  patient  is  so  great  and 
the  symptoms  so  alarming,  that  few  men  are  brave 
enough  to  really  an;csthetizc  their  patients  and  opera- 
tions are  nearly  always  performed  before  surgical  anaes- 
thesia is  induced,  and  this  is  the  reason  that  so  many 
fail  with  nitrous  oxid  gas.  The  patient  feels  and  knows 
everything  that  is  done,  because  he  is  not  surgically 
anaesthetized.      Most    operations    under    nitrous    oxid 


184  General  Ancesthetics  in  Dentistry. 

are  performed  in  the  analgesic  rather  than  the  anaes- 
thetic stage,  and  a  large  number  are  absolute  failures, 
and  it  would  have  been  better  for  both  the  patient  and 
the  operator,  had  nitrous  oxid  not  been  administered. 
Discredit  is  brought  upon  a  good  anaesthetic  and  often 
upon  a  good  appliance  by  attempting  extraction  and 
surgical  operations  when  the  patient  is  not  surgically 
anaesthetized.  I  say  without  hesitancy,  that  I  con- 
sider the  stage  of  surgical  anaesthesia  induced  by  pure 
nitrous  oxid  as  dangerous,  and  even  mor6  so,  than  the 
stage  of  surgical  anaesthesia  induced  by  somnoform. 
I  will  also  add  that,  if  from  fear  you  stop  short  of  the 
stage  of  anaesthesia  with  somnoform,  as  is  nearly  al- 
ways done  with  nitrous  oxid,  you  can  accomplish  as 
much  again  with  somnoform  as  with  nitrous  oxid  and 
not  hurt  your  patient  or  have  them  struggle  and  resist 
as  they  do  under  nitrous  oxid. 

There  is  this  to  say  in  favor  of  nitrous  oxid,  that  the 
"leave-off"  symptoms  are  very  pronounced,  while  with 
somnoform  this  is  not  the  case.  There  is  no  cyanosis, 
no  jactitation,  no  rolling  of  the  eyeballs  or  stertorous 
breathing,  but  a  beautiful  tranquil  sleep  in  most  cases 
and  nothing  alarming  to  either  the  anaesthetist  or  any 
friend  that  may  be  present.  Approaching  anaesthesia 
can  always  be  told  when  somnoform  is  the  anaesthetic 
employed,  as  surely  as  when  nitrous  oxid  is  used ;  l^ut 
when  surgical  anccsthesia  is  induced  with  somnoform, 
the  patient  is  in  a  condition  of  safety,  while,  when  the 
stage  of  surgical  anaesthesia  is  reached  under  pure  ni- 
trous oxid,  the  patient  is  dangerously  asphyxiated. 

You  can  produce  death  with  these  anaesthetics  by 


General  Ancesthctics  in  Dentistry.  185 

holding  the  inhaler  tightly  over  the  nose  and  face, 
excluding  all  air,  hut  with  proper  precautions  and  care- 
ful watching-  death  rarely  occurs  under  any  anaesthetic. 
In  more  than  six  thousand  somnoform  anaesthesias, 
I  have  never  witnessed  an  alarmini^  or  dangerous 
symptom. 

Somnoform  is  a  transparent  liquid  preparation  ready 
for  use,  in  glass  tubes  and  capsules,  sold  by  all  dental 
dealers,  the  tubes  contain  sixty  grammes,  while  the 
capsules  are  made  in  two  sizes,  one  containing  3  cubic 
centimeters  and  the  other  5  cubic  centimeters.  To  the 
tubes  or  bottles  is  attached  a  valve  by  means  of  which 
the  somnoform  is  sprayed  into  the  inhaler.  These  tubes 
have  a  centimeter  scale  on  the  side  and  the  distance 
from  one  division  line  to  the  other  contains  5  c.  c.  In 
spraying  into  the  inhaler,  the  tube  is  turned  valve  end 
down  and  held  in  a  perpendicular  position.  As  soon 
as  the  somnoform  steadies  itself,  you  note  its  position 
on  the  scale ;  it  settles  in  the  bottle  as  it  is  sprayed  out. 
It  only  took  the  contents  of  two  of  these  tubes  to  con- 
vince me  that  the  capsules  must  be  preferaljle.  Unless 
the  entire  contents  of  one  of  these  tubes  is  used  in  a 
short  time,  the  unused  portion  has  a  peculiar  odor, 
and  the  longer  it  remains  in  the  tul)e  the  more  offen- 
sive it  becomes.  I  thought  at  first  that  the  materials 
forming  this  mixture  had  decomposed.-  l)ut  later  it  oc- 
curred to  me  that  the  valve  no  doubt  leaked  a  little 
and  that  the  more  volatile  constituents  of  the  somno- 
form were  evaporating  leaving  the  heavier  bromine 
proportion.  This,  I  am  satisfied,  is  exactly  what  hap- 
pens to  the  contents  of  the  60-gramme  tubes.    Upon  in- 


186 


General  Anccsthetics  in  Dentistry. 


quiry  I  have  ascertained  that  those  dentists  who  com- 
plain most  about  somnoform  producing  nausea  have 
been  using  the  large  tubes.  ! 


A  SOMNOFOEM  CAPSULE. 


BOX   IIOLDINCi    TWELVE    CAPSULES. 

Luke  says  that  ethyl  f^romidc  used  as  an  anaesthetic 
is  followed  by  nausea  in  forty-five  per  cent,  of  the 
administrations  made. 


General  Aiiccstlwtics  in  Dentistry.  187 

The  capsules  are  hermeiically  sealed,  there  is  no 
opportunity  for  leakage  or  decomposition  and  we  al- 
ways know  the  exact  quantity  with  which  we  have  to 
deal.  For  a  period  of  three  years,  I  confined  myself  to 
the  use  of  the  5  c.  c.  capsules,  taking  it  for  granted  that 
with  that  amount  of  somnoform  I  could  get  a  better 
result  than  by  using  the  smaller  size. 

On  one  occasion  my  dealer  being  out  of  5's,  I  pur- 
chased 3's  and  have  used  them  almost  entirely  ever 
since.  Even  with  the  3's  I  am  confident  that  not  more 
than  half  of  the  contents  of  these  smaller  tubes  are 
used,  and  I  find  myself  wishing  that  the  manufactur- 
ers would  make  a  tube  containing  but  two  cubic 
centimeters. 

The  Stark  Inhaier. 

The  Stark  inhaler  may  be  said  to  consist  of  three 
parts.  The  face-piece  is  made  of  metal  instead  of  cel- 
luloid and  this  permits  of  its  being  boiled  before  and 
after  use  just  as  any  other  surgical  appliance.  Inside 
of  the  Stark  metal  face-piece  is  soldered  a  piece  of 
metal  gauze.  When  somnoform  is  to  be  followed  by 
ether  or  chloroform,  a  piece  of  surgeon's  gauze  is 
placed  in  the  face-piece  on  the  metal  gauze.  As  soon 
as  the  patient  is  deeply  anaesthetized  with  scMunoforni, 
the  face-piece  is  detached  from  the  appliance  and  now 
becomes  an  ether  or  chloroform  inhaler,  the  drop 
method  being  employed.  The  change  can  be  made  in 
the  fraction  of  a  second  and  the  ether  or  chloroform 
simply  dropped  on  the  surgeon's  gauze.     In  the  hori- 


188 


General  Ancesthetics  in  Dentistry. 


zontal  tube  is  an  opening  on  each  side  for  the  admis- 
sion of  air.  Just  back  of  these  openings  is  a  device  for 
regulating  both  the  amount  of  air  and  the  amount  of 
somnoform  that  shall  be  inhaled  by  the  patient.   This 


STAEK  SOMNOFOEM  INHALER. 


device  is  regulated  by  means  of  a  small  handle  or  lever 
moved  backward  or  forward  by  the  thumb  of  the  hand 
that  holds  the  inhaler.  By  means  of  this  simple  device 
the  amount  of  somnoform  inhaled  can  be  regulated  to 


General  Aiucstlietics  in  Dentistry. 


189 


a  certainty.     If  you  so  wish,  all  of  the  somnofonn  can 
be  excluded  and  only  air  admitted.     The  patient  with 


INFLATAHLE 
RUBBER    MARGIN 


SEE    LARGER 
ILLUSTRATION    BELOV> 
LEVT.R 
AND   SLint 
ClOSINd  AlK  V 
SOM>iOKOHN 


Aft*    OPKNING 


TtLBSCOPlNG 

CAl' 

CAI'SLI.E 


(CHAMBKH 


VALvfe 


SOMNOFOHN  V\Lia 

AlH    OPKNINGS 

LEVKR   CONTROLLING 
BOTH 


KRAMEWOHK 
SF-PAHATES  TO 
pMPTV  BROKEN 

Ola«5s  hkli>  by 

(.AtZE 

WIHKS   TO 
SUPPORT  LUST 


COVERS   WIRES 
AND    LINT 


SHOULDER  AND 
FLATMGE 
SUPPORTING  BAG 


DETAILED   CONSTRUCTION   OF  STARK   SOMNOFORM 
INHALER. 

the  inhaler  in  position,  can  breathe  for  any  length  of 
time  desired  without  "getting  so  much  as  a  trace  of  the 


190  General  Anaesthetics  in  Dentistry. 

anaesthetic.  You  can  admit  just  an  odor,  at  first,  and 
increase  it  as  slowly  or  as  rapidly  as  you  desire  for  each 
individual  case.  The  amount  of  anaesthetic  inhaled  is 
absolutely  under  your  own  control.  More  than  this, 
when  the  patient  is  anaesthetized,  the  somnoform  can 
be  shut  in,  its  escape  prevented,  and  again  turned  on  at 
the  desired  time.  I  have  fractured  a  5  c.  c.  tube  of  som- 
noform in  my  Stark  appliance,  and  thirty  minutes  later 
found  sufficient  remaining  in  the  bag  to  anaesthetize 
a  patient. 

On  the  back  of  the  perpendicular  tube  is  soldered  a 
smaller  brass  tube  just  the  size  to  hold  a  5  c.  c.  capsule 
of  somnoform.  Of  course,  if  it  holds  a  5„  it  will,  also 
hold  a  3  c.  c.  capsule,  but  not  at  the  same  time.  The 
capsule  in  position,. the  cover,  another  brass  tube  tele- 
scopes over  the  capsule,  and  when  the  patient  is  ready, 
slight  pressure  on  the  telescoping  tube  fractures  the 
capsule  and  the  contents  collect  on  the  absorbent  lint, 
or  surgeon's  gauze,  in  a  receptacle  beneath  made  for 
the  purpose.  A  rubber  bag  is  attached  to  the  lower 
part  of  the  appliance  to  prevent  the  somnoform  escap- 
ing after  being  liberated  from  its  capsule. 

A  special  appliance  is  necessary  for  somnoform  on 
account  of  its  volatile  nature.  After  once  leaving  its 
capsule,  it  evaporates  so  rapidly  that  it  is  impossible 
to  confine  it  in  any  appliance  without  a  rubber  bag.  On 
one  occasion  I  went  with  an  oculist  to  the  residence  of 
a  patient  to  administer  somnoform  for  an  eye  enu- 
cleation. Upon  arriving,  I  discovered  that  I  had  failed 
to  bring  the  rubber  bag.  We  tried  first,  holding  a  nap- 
kin over  the  bottom  of  the  appliance  where  the  bag  is 


General  AiKrsthetics  in  Dentistry.  191 

attached  and  wasted  four  or  five  5  c.  c.  capsules.  Then 
we  tried  cotton  underneath  and  a  napkin  over  that  and 
wasted  two  or  three  more  5"s  and  gave  up  in  disgust. 
The  next  day  we  returned  and  with  one  3  c.  c.  capsule 
inckiced  an  anaesthesia  sufficient  for  the  enucleation, 
and,  when  the  jjalient  returned  to  consciousness  the 
handagc  was  in  i)osition,  the  last  pin  just  being 
inserted. 

Ethyl  chloride  can  be  administered  without  a  bag; 
so  can  ethyl  bromide,  but  sonmoform  must  be  con- 
tained. If  you  will  take  a  3  c.  c.  capsule  of  somnoform 
and  hold  it  a  little  higher  than  the  head  and  fracture 
the  point  by  striking  it,  the  fluid  will  not  hit  the  floorj 
it  will  vaporize  before  it  gets  that  far. 

The  DeFord  Somnoform  Appliance. 

The  DeFord  Somnoform  Appliance  is  a  modification 
of  and  an  improvement  on  the  Stark  Inhaler.  It  pro- 
vides a  means  of  continuing  somnoform  inhalation 
after  the  patient  is  ready  to  be  operated  on  in  opera- 
tions in  and  about  the  mouth,  nose  and  eyes.  In  all 
such  operation  the  Stark  inhaler  must  be  removed 
from  the  face  when  the  surgeon  begins  to  operate,  but 
the  DeFord  Appliance  makes  it  po^siMeCto  induce  con- 
tinuous anesthesia  while  operating,  as  is  done  under 
nitrous  oxid  and  oxygen  anaesthesia."  Provision  is  also 
made  to  continue  the  somnoform  anaesthesia  if  desired 
by  the  use  of  ether  or  chloroform  without  removing 
the  appliance  from  its  position  cm  the  face. 

The  appliance  is  strapped  on  the  head  in  the  same 
manner  as  a  nasal  inhaler  for  nitrous  oxid  and  oxv- 


192 


General  AuccstJietics  in  Dentistry. 


gen.  By  means  of  a  metal  rod  a  mouth  piece  is  at- 
tached to  the  nasal  inhaler.  With  the  mouth  propped 
open  wide,  the  mouth  cover  is  adjusted  in  proper  rela- 
tion to  the  nasal  inhaler,  covering  the  mouth,  and  fas- 


NASAL  INHALER 
SPONGE  RUBBER /SUP^'NT  CONNECTION 
ADAPTER  ^BU^ttmkOR  SOMNOFORM   VALVE 


FLAT   SPRING 
SUPPORTING  TUBE 


ANESTHESIA     INDUCTION— DeFOKD     SO.MNOFORxM 
APPARATUS. 


teucd  tight  to  the  rcjd  l)y  a  set  screw.  When  the  pa- 
tient is  anaesthetized  the  mouth  cover  is  everted  and 
is  held  up  out  of  the  way  of  the  operator  by  a  holding 
device  attached  to  the  nasal  piece.     If  patient  shows 


M 


^rf 


General  AiKrsthetics  in  Dentistry.  193 

signs  of  regaining  consciousness,  this  mouth  cover  can 
be  dropped  into  its  former  position  over  the  mouth, 
excluding  the  air,  and  only  two  or  three  inhalations 
are  necessary  to  reinduce  anaesthesia.  On  top  and  a 
little  to  one  side  is  an  exhalation  valve.  By  a  half 
turn  of  the  thumb  and  tinger  this  valve  can  easily  be 
opened  or  closed.  When  open  the  exhalation  of  the 
patient  escapes;  when  closed  it  aids  in  rebreathing. 
A  soft  rubber  rim  is  attached  to  the  nasal  piece, 
making  a  closer  face  adaptation  and  the  appliance 
more  comfortable.  On  the  sides  are  metal  buttons 
for  the  attachment  of  a  strap  or  elastic  for  fastening 
the  appliance  to  the  head.  This  part  of  the  appliance 
is  identical  with  the  DeFord  Nitrous  Oxid  Inhaler. 

At  the  place  where  the  rubber  tubing  would  be  at- 
tached to  the  inhaler,  if  nitrous  oxid  was  going  to  be 
used,  is  fastened  a  metal  tube  in  which  is  soldered  a 
valve  for  regulating  the  amount  of  anaesthetic  and 
amount  of  air.  This  valve  is  in  plain  sight  of  the  oper- 
ator so  he  can  see  at  all  times  the  adjustment,  whether 
the  operation  be  that  of  extracting  or  sensitive  cavity 
preparation.  A\'hen  the  mouth  cover  is  everted  no 
matter  what  may  be  the  operation,  somnoform  can  be 
inhaled  all  during  the  operation  through  the  nasal  in- 
haler. Breathing  once  established  through  the  nose  is 
apt  to  continue  after  the  mouth  cover  is  everted.  If 
this  should  not  maintain  anaesthesia  sufficiently  pro- 
found, drop  the  mouth  cover  as  occasion  demands. 

A  rubber  tube  leads  from  the  valve  to  the  break- 
ing device.  The  tubing  passes  up  over  the  head  and 
the   rubber  bag  hangs   down   back  of  the   head  out 


194  General  Anccsthetics  in  Dentistry. 

of  the  way  of  the  hand  of  the  patient  if  he  should 
attempt  to  grab  the  bag. 

A  somnoform  capsule  is  placed  in  the  breaking  de- 
vice and  fractured  by  pressing  the  telescoping  top. 
Gauze  or  cotton  is  placed  in  the  anaesthetic  chamber 
which  takes  up  the  liberated  somnoform.  In  this 
breaking  device  can  be  dropped  ether  or  chloroform  to 
be  used  in  connection  with  somnoform,  or  used  in  se- 
quence. On  the  bottom  of  the  anaesthetic  chamber  is 
fastened  a  rubber  bag  for  confining  the  anaesthetic 
vapors. 

For  operations  on  teeth  other  than  extracting,  the 
rubber  dam  being  adjusted,  the  mouth  cover  can  be 
instantanously  removed,  simply  sliding  over  a  metal 
pin  to  the  left.  When  rubber  dam  is  not  used,  the 
mouth  cover  can  be  retained  in  position  and  dropped 
down  over  the  mouth  for  an  inhalation  or  two,  as 
needed. 


General  Anccsthctics  hi  Dentistry.  195 


LECTURE  XVI. 
Somnoform — Continued. 

Other  things  being  equal,  the  anaesthetic  that  dis- 
turbs physiological  functions  the  least  must  be  a  desir- 
able anaesthetic.  The  anaesthetic  agent  that  maintains 
the  pulse  rate  near  the  normal,  that  interferes  but 
slightly  with  respiration,  that  does  not  accumulate  in 
the  system,  that  does  not  alter  the  secretions  of  the 
kidneys,  that  does  not  change  the  blood  chemically, 
that  seldom  nauseates,  is  rarely  followed  by  headache 
or  unpleasant  after-results,  and,  in  addition,"  one  that 
quickly  anaesthetizes  and  is  quickly  eliminated  and  not 
difficult  to  administer  is,  indeed,  an  anaesthetic  worthy 
of  investigation.    Such  an  anaesthetic  is  somnoform. 

A  patient  about  to  be  anaesthetized,  no  matter  how 
trivial  the  operation,  or  how  safe  the  anaesthetic  agent 
employed,  is  more  or  less  nervous  and  excited.  It  is 
seldom  that  a  patient  takes  the  dental  chair  to  be  anaes- 
thetized that  he  does  not  have  an  accelerated  pulse. 
Physicians,  accompanying  patients  to.  my  office  to  wit- 
ness an  extraction  under  somnoform  anaesthesia,  have 
frequently  called  attention  to  the  fact  that  a  pulse  of 
150  or  higher,  at  the  beginning  of  the  administration, 
falls  to  about  80  or  85  and  is  maintained  at  that  during 
the  operation.  In  other  patients,  the  pulse  may  not  beat 


196  General  Anccstheiics  in  Dentistry. 

more  than  90  per  minute  upon  taking  the  chair,  but 
usually  quiets  down  to  a  little  above  normal.  While 
somnoform,  no  doubt,  increases  the  heart's  action  at 
the  beginning  of  the  anaesthesia,  I  am  inclined  to  be- 
lieve that  a  pronounced  acceleration  is  the  result  of 
nervousness  and  anxiety  on  the  part  of  the  patient.  It 
is  no  unusual  occurrence  for  the  pulse  to  increase  its 
action  perceptibly  and  sometimes  disastrously  during 
an  examination  for  life  insurance,  even  w^hen  no  heart 
abnormality  is  present. 

There  are  a  few  patients  who  maintain  their  ner- 
vous equilibrium  to  such  a  degree  as  not  to  show  ex- 
citement when  about  to  be  anaesthetized.  The  pulse, 
in  these  exceptional  cases,  under  somnoform,  in  the  be- 
ginning, is  usually  augmented  ten  to  fifteen  beats  per 
minute,  but  when  completely  anaesthetized  resumes  the 
normal,  or  just  a  little  above  the  normal. 

My  experience  with  somnoform  has  shown  the 
pulse  to  be  more  of  an  ether  than  a  chloroform  pulse; 
full,  bounding  and  regular.  Somnoform- is  eliminated 
quickly,  the  patient  being  slightly  stimulated,  wonder- 
fully pleased,  talkative  and  buoyant.  Even  quiet  peo- 
ple talk  fluently,  and  talkative  patients  for  several  min- 
utes will  repeat  time  and  again  their  dream  or  experi- 
ence during  anaesthesia,  amazed  and  delighted  at  the 
result  obtained.  I  recall  the  case  of  an  attorney  for 
whom  I  extracted  a  third  molar.  He  was  a  large  man, 
weighing,  I  should  say,  more  than  two  hundred  and 
fifty  pounds.  I  operated  for  this  man  at  about  11  A.  M., 
and  I  never  had  a  more  pleased  patient  in  ^my  life. 
About  1  o'clock,  he  returned  to  the  office  and  said : 


General  Aiucsthetics  in  Dentistry.  197 

"I  wish  again  lo  thank  you  for  the  operation  you  made 
for  me  this  morning,  and  I  wish  that  you  would  show 
me  that  appliance ;  I  want  to  know  just  how  it  works." 
This  is  only  one  instance  of  the  appreciation  shown  by 
nearly  everyone  for  whom  I  have  operated  under  som- 
noform.  I  think  I  may  safely  say  that  ninety-five  per 
cent,  of  the  patients  to  whom  I  have  administered 
somnoform  regain  consciousness  in  a  state  of  com- 
fortable or  joyous  stimulation.  They  can  not  thank 
you  often  enough  and  they  volunteer  to  send  all  their 
friends  and  neighbors.  I  recall  a  fine  old  gentleman 
past  seventy-five  years  of  age.  I  extracted  seven  teeth 
for  him  under  somnoform  anaesthesia,  and  he  ran  his 
hand  into  his  pocket  and  paid  the  fee  before  he  left 
the  chair.  He  remarked  that  his  daughter  had  suffered 
for  years  with  her  teeth,  and  he  would  have  her  pay 
me  a  visit.  The  next  day  she  arrived.  She  remarked, 
"Father  drove  home  from  your  ofBce,  alone,  thirteen 
miles,  after  you  operated  for  him,  put  his  horse  in  the 
stable  and  came  direct  to  my  home,  before  going  into 
his  house,  to  tell  me  about  it" — another  example  of 
somnoform  stimulation. 

Rarely  does  anyone  become  exhausted  unless  ovor- 
ansesthetized,  as  the  result  of  somnoform  anaesthesia. 
I  have  had,  perhaps,  a  dozen  cases  in  which  I  allowed 
the  patient  to  rest  a  few  minutes  before  leaving  tiie 
office.  In  each  of  these  cases,  I  administered  more 
somnoform  than  necessary,  or  the  patient  was  more 
thaia  ordinarily  susceptible  to  its  influence. 

The  respiration  at  the  beginning  of  somnoform  in- 
duction is  usually  what  the  anaesthetist  makes  it.     By 


J.98  General  Anccsthetics  in  Dentistry. 

this  I  mean  that  the  patient  tries  to  breathe  as  in- 
structed. I  say  nothing  about  the  breathing  vmtil  I 
ascertain  by  observation  the  respiration  of  the  patient. 
Very  seldom  is  it  necessary  to  make  any  suggestion 
in  regard  to  respiration.  By  giving  directions  in  ad- 
vance, the  patient  becomes  confused  and  alarmed  and 
breathes  every  way  but  the  way  you  desire.  Sa}^  noth- 
ing and  you  will  succeed  far  better  than  by  giving  the 
minutest  instruction. 

Ordinary  respiration  is  sufficient  to  oxygenate  the 
blood,  and  ordinary  respiration  is  sufficient  to  somno- 
form  the  blood.  After  the  appliance  is  adjusted,  if  the 
patient  continues  to  breathe  normally,  in  a  few  seconds 
the  respiration  will  become  deeper  and  slower.  Should 
this  occur  there  is  no  need  for  alarm,  it  is  physiological 
with  somnoform.  Should  the  patient  after  the  first  few 
inhalations  begin  to  take  shorter  and  shorter  breaths, 
amounting  almost  to  "panting,"  in  a  low,  firm  voice 
suggest  deeper  breathing.  If  short  respiration  is  con- 
tinued, remove  the  inhaler,  or  shut  ofif  all  somnoform 
until  normal  breathing  is  resumed.  With  the  kind  of 
breathing  described,  the  patient  is  more  apt  to  become 
asphyxiated  than  anaesthetized,  no  matter  what  anaes- 
thetic agent  is  employed. 

When  I  procured  my  first  somnoform  appliance,  I 
studied  the  directions  for  three  weeks  before  making  an 
administration.  My  first  patient  was  an  athletic  young 
fellow,  a  foot-ball  player,  who,  in  a  practice  game, 
fractured  his  left  central  and  lateral  incisors,  the  pulps 
remaining  in  position.  The  directions  that  came  with 
the  somnoform  appliance,  said,  "Instruct  the  patient  to 


General  Anoesthetics  in  Dentistry.  199 

breathe  deeply,  and  when  the  first  exhalation  passes 
into  the  rubber  bag,  break  the  capsule  and  exclude  all 
air."  As  I  had  administered  nitrous  oxid  for  more  than 
twenty  years,  I  thought  I  knew  what  deep  breathing 
meant,  so  I  showed  my  patient  in  advance  how  1 
wished  him  to  breathe.  He  did  just  as  I  told  him. 
The  first  inhalation  he  received  all  air,  and  no  anaes- 
thetic ;  on  the  second  inhalation  the  air  was  excluded 
from  the  appliance  and  he  received  all  somnoform  with 
the  air  he  had  exhaled  into  the  bag.  His  head  fell  to 
one  side  like  he  had  been  hit  with  a  black-jack.  I  re- 
moved the  pulps  and  then  took  out  my  watch  and 
timed  him.  His  pulse  was  strong,  his  respiration  a  lit- 
tle deeper  than  normal,  and  he  slept  as  quietly  and  as 
peacefully  as  a  child  for  the  period  of  six  minutes. 
The  same  afternoon  a  girl,  fourteen  years  of  age,  pre- 
sented with  the  lower  sixth  year  molars  on  each  side 
broken  down.  I  instructed  her  to  breathe  about  half 
as  deeply  as  the  young  man,  and  allowed  her  to  take 
three  inhalations  with  all  air  excluded,  extracted  the 
teeth  and  could  have  removed  others.  After  a  while 
I  learned  that  deep  breathing  was  not  essential  to  som- 
noform anaesthesia,  and  at  the  present  time,  as  inti- 
mated above,  prefer  normal  breathing  in  nearly  all 
cases. 

Occasionally  a  nervous  child  or  a  hysterical  woman, 
at  the  very  beginning  of  sonmoform  induction,  will 
hold  their  breath  and  refuse  to  breathe.  The  longer 
the  breath  is  lield,  the  deeper  will  be  the  next  inhala- 
tion. It  is  important  just  here  to  watch  closely.  The 
inhaler  should   be   removed  or  the   vahc   closed,   pre- 


200  General  Anesthetics  in  Dentistry. 

venting  the  somnoform  from  escaping,  as  it  would  be 
dangerous  to  inhale  pure  somnoform  at  the  next  in- 
halation. You  will  recall  that  many  patients  die  when 
chloroform  is  administered  when  only  two  or  three 
inhalations  have  been  taken.  The  vapor  was  too 
strong  or  the  inhalations  too  deep. 

It  is  evident  that  somnoform  does  not  accumulate  in 
the  system,  because  the  patient  recovers  consciousness 
very  quickly  no  matter  how  long  the  anaesthetic  state 
is  maintained.  My  longest  somnoform  anaesthesia 
lasted  twenty-five  minutes,  and  in  a  minute  after  re- 
moving the  inhaler  the  patient  was  wide  awake.  This 
was  a  case  of  crushed  fingers.  The  surgeon  thought 
five  minutes  would  be  ample  for  the  operation,  but  the 
case  proved  to  be  more  complicated  than  at  first  sup- 
posed. At  the  end  of  five  minutes  I  suggested  ether, 
or  chloroform,  but  there  was  neither  in  the  office  of  the 
physician,  and  the  operation  would  have  been  discon- 
tinued if  either  of  us  went  to  a  drug-store,  so  there  was 
nothing  to  do  but  continue  with  somnoform.  I  used 
ten  5  c.  c.  tubes,  and  the  patient  left  the  office  in  less 
than  three  minutes  after  the  anaesthetic  was  discon- 
tinued. 

Dr.  Bronson,  a  dentist  residing  at  Gowrie,  Iowa, 
told  me  that  he  anaesthetized  his  sister-in-law  with 
somnoform  for  a  surgical  operation,  and  maintained 
surgical  anaesthesia  for  thirty-five  minutes.  I  had  an 
opportunity  to  talk  with  the  patient  and  had  her  give 
me  a  history  of  the  case.  She  had,  on  previous  occa- 
sions, been  anaesthetized  with  both  ether  and  chloro- 
form and  was  in  a  position  to  make  a  comparison.    She 


General  Anasthetics  in  Dentistry.  201 

informed  me  that  the  somnoform  anaesthesia  was  in  no 
way  unpleasant  and  that  she  awoke  just  as  she  did 
mornings  from  natural  sleep.  She  felt  no  pain  what- 
ever during  the  operation.  There  was  no  nausea,  such 
as  she  had  experienced  with  ether  and  chloroform.  The 
anaesthetist  told  me  he  had  hardly  removed  the  inhaler 
when  she  was  wide  awake.  1  mention  these  cases  to 
show  that  somnoform  is  not  cumulative  in  the  sense 
that  ether  and  chloroform  are  cumulative.  1  have  had 
brought  to  my  notice  a  few  cases  where  patients  were 
drowsy  and  wanted  to  sleep  after  the  operation.  This 
is  common  to  chloroform  and  ether,  but  seldom  occurs 
as  a  sequence  to  nitrous  oxid  and  somnoform.  Hewitt, 
however,  mentions  a  case,  reported  to  him  by  a  physi- 
cian, of  a  patient  who  slept  for  three  days  after  an 
anaesthesia  induced  by  nitrous  oxid  gas. 

Dudley  Buxton,  the  English  anaesthetist,  says,  "Dr. 
Swain  has  examined  the  blood  of  patients  before  and 
after  taking  somnoform  and  found  no  change  in  the 
amount  of  haemoglobin  or  in  the  number  of  leucocytes. 

Urinary  analyses  have  been  made  prior  to  and  at 
the  conclusion  of  somnoform  anaesthesia  and  no  alter- 
ation in  the  specific  gravity  or  nature  of  the  urine  has 
been  observed.     [Buxton.] 

Somnoform,  so  far  as  I  have  been  able  to  observe, 
does  not  irritate  the  mucous  membrane;  nor  does  it 
irritate  the  nerves  of  the  nares,  pharynx,  larynx,  tra- 
chea, bronchi  or  lungs.  Its  non-irritability  is  an  ele- 
ment of  safety  well  worth  mentioning.  From  the  fact 
that  it  does  not  irritate  the  mucous  membrane,  there 
is  an  absence  of  accumulation  of  mucus  in  the  throat. 


202  •     General  Anccsthetics  in  Dentistry. 

such  as  we  always  have  accompanying  the  administra- 
tion of  ether.  This  mucus  sometimes  almost  defeats 
surgical  anaesthesia,  and  the  anaesthetist  must  discon- 
tinue frequently  and  swab  out  the  throat  to  prevent 
suffocation. 

From  the  fact  that  somnoform  does  not  irritate  the 
nerves,  we  can  almost  eliminate  the  condition  known 
as  Laryngo  Reflex,  "Syncope  of  Duret."  Irritating 
anaesthetic  vapors  sometimes  reflexly  cause  paralysis 
of  the  respiration  and  circulation,  which  has  already 
been  considered  in  a  previous  lecture  under  "Spasm 
of  the  Glottis." 

From  the  fact  that  somnoform  is  non-irritating  to 
the  respiratory  apparatus,  it  is  indicated  especially  in 
minor  surgical  operations,  and  for  all  patients  afflicted 
with  pulmonary  disorders. 

Nitrous  oxid  causes  enlargement  of  the  tongue 
and  the  soft  tissues  of  the  pharynx  and  throat  from 
venous  engorgement.  Patients  having  hypertrophied 
tonsils,  adenoid  vegetations  in  the  upper  pharynx,  en- 
larged or  oedematous  uvula  or  abnormal  growths  or 
neoplasms  of  the  throat  are  far  more  comfortably  anaes- 
thetized with  somnoform  than  nitrous  oxid.  Nitrous 
oxid  increases  the  size  of  all  these  tissues,  already  ab- 
normally enlarged,  while  there  is  no  change  in  the  size 
of  the  tissues  or  organs  named  when  somnoform  is  the 
anaesthetic  agent  used. 

Nausea  is  not  a  very  common  occurrence  during 
or  following  somnoform  auccsthesia.  Rolland  claims 
but  one  per  cent,  of  nausea. 

1  can  well  understand  why  some  anaesthetists  have 


General  Anccsthctics  in  Dentistry.  303 

more  nausea  than  others.  Nausea  depends  mostly  on 
three  conditions :  First,  administering  an  auccsthetic 
on  a  full  stomach,  or  too  soon  after  eating.  This  cause 
I  will  eliminate,  because,  as  dental  surgeons  operate 
largely  for  patients  under  nitrous  oxid  and  somnoforni 
just  when  they  happen  to  come  to  the  office,  one  den- 
tist is  as  apt  to  get  patients  of  this  kind  as  an<jther. 
Second,  some  operators  insist  on  a  deeper  somnoform 
anaesthesia  than  necessary.  This  is  a  mistake  that 
most  men  make  with  somnoform;  they  anaesthetize 
their  patients  deeper  than  is  necessary,  usually,  for  the 
operation  to  be  performed.  Where  but  one  or  two 
teeth  are  to  be  extracted,  an  anaesthesia  is  induced 
sufficient  for  double  the  amount  of  work  to  be  done. 
This  fallacy  can  be  corrected  only  by  experience.  It 
is  more  common  to  those  accustomed  to  administering 
nitrous  oxid  gas  than  to  those  who  have  not  had  ni- 
trous oxid  experience.  The  nitrous  oxid  man  has  ac- 
quired the  habit  of  strenuously  excluding  all  air  and 
having  the  patient  breathe  deeply.  The  habit  is  so 
fixed  it  is  difficult  to  modify  it.  Then,  the  nitrous  oxid 
man  has  been  accustomed  to  such  pronounced  "leave- 
oiif"  symptoms,  dusky  countenance  and  cyanosis,  loud 
stertorous  breathing,  jactitation,  etc.,  that  it  takes  him 
some  time  to  recognize  the  less  pronounced  somnoform 
anaesthesia  indications.  Over-anassthetization,  I  think 
is  the  most  common  cause  of  nausea.  Third,  exclusion 
of  all  air  is  provocative  of  nausea,  also.  When  som- 
noform was  first  introduced  into  this  country,  the  di- 
rections advocated  that  only  one  inhalation  of  air  be 
taken,  then  to  exclude  all  air  and  breathe  deeply.   Two 


204  General  Anccsthctics  in  Dentistry. 

administrations  following  the  directions  convinced  me 
that  a  safer  and  more  rational  method  should  be 
adopted  of  inducing  somnoform  anaesthesia,  and,  from 
that  day  to  this,  I  have  been  advocating  more  air  and 
normal,  or  just  a  little  more  pronounced  than  normal 
breathing. 

I  have  already  referred  to  nausea  follov^ing  the 
administration  of  somnoform  from  a  partially  used  60- 
gramme  bottle.  In  my  own  practice,  nausea  is  a  rare 
occurrence.  In  more  than  6,000  somnoform  anaesthe- 
sias I  have  experienced  only  about  a  dozen  cases  of 
nausea  where  blood  was  not  swallowed.  This  record 
is  not  confined  to  somnoform  anaesthesias  for  the  ex- 
traction of  teeth  alone,  but  includes  somnoform  ad- 
ministration for  removal  of  tonsils,  amputation  of  fin- 
gers, ingrowing  toe  nails,  opening  abscesses,  lancing 
felons,  vaginal  and  uterine  operations,  and  for  various 
minor  surgical  cases.  Indeed,  I  cannot  recall  nausea 
in  a  single  instance  of  somnoform  anaesthesia,  for  con- 
ditions other  than  extraction  of  teeth  and  nose  and 
throat  operations. 

I  recall  an  interesting  case  at  the  Methodist  Hos- 
pital. One  of  our  leading  surgeons  called  upon  me 
to  "guarantee"  that  I  could  administer  somnoform  to 
one  of  his  patients  without  supervening  nausea.  This 
patient  had  been  recently  operated  upon  and  had  been 
so  badly  nauseated  with  ether  that  severe  vomiting 
had  made  it  necessary  to  remove  the  stitches,  re-open 
the  wound  for  re-examination  and  reparation  of  dam- 
ages. He  insisted  that  it  would  not  do  to  have  this 
patient  nauseated  again.     I  told  him  I  could  promise 


General  Ancestlietics  in  Dentistry.  205 

nothing"  in  sucli  a  case,  but  was  confident  that  somno- 
form  would  be  less  apt  to  nauseate  than  any  other, 
anaesthetic.  He  thought  that  a  five-minute  anaesthesia 
would  be  sufficient.  In  this  case,  the  lightest  anaesthe- 
sia possible  for  comfortable  operating  was  decided 
upon.  I  asked  one  of  the  nurses  to  take  the  patient's 
hand,  and,  when  the  patient's  hand  lost  its  grip  or 
relaxed,  to  follow  the  movements  of  the  hand  with  her 
disengaged  hand.  When  the  nurse's  hand  started  to 
close,  I  knew  that  the  patient  needed  more  anaesthetic 
and  when  the  nurse's  hand  was  relaxed,  I  knew  that 
the  patient's  hand  was  relaxed,  so  I  admitted  air.  The 
patient's  hand  was  under  the  sheet  where  I  could  not 
observe  it.  With  this  test  for  surgical  anaesthesia,  I 
held  the  patient  under  somnoform  anaesthesia  for  a 
period  of  nine  minutes,  and  1  learned  afterwards  there 
was   no  supervening  nausea. 

Just  recently  a  young  girl  about  nineteen  years  of 
age  was  referred  to  me  for  an  extraction  under  somno- 
form anaesthesia.  Her  mother  told  me  that  she  would 
surely  become  nauseated,  that  even  the  smell  of  meat 
broiling  would  make  her  sick,  and  that  odors  agreeable 
to  other  people  would  nauseate  her.  Of  course,  I  ex- 
pected nausea,  but  suggested  all  during  the  induction 
of  anaesthesia  that  she  would  not  be  sick,  and  she  was 
not. 

An  elderly  lady  insisted  that  sonmoform  would 
nauseate  her,  and  1  insisted  that  it  would  not.  Then 
she  told  me  that  on  a  previous  occasion  she  suffered 
for  five  days  with  nausea  after  an  ether  anaesthesia, 
and  that  the  physician  despaired  of  her  life.     After 


206  General  Anesthetics  in  Dentistry. 

regaining  consciousness  she  swallowed  a  little  air  and 
belched  it  up,  but  did  not  succeed  in  emptying  her 
stomach.  I  said  to  her,  "There  is  no  use  trying;  you 
can't,  and  you  know  that  you  can't."  She  replied,  "I 
guess  I  can't."  I  'phoned  her  in  the  afternoon  and  as- 
certained that  she  had  not  been  the  least  bit  nauseated 
after  returning  home. 

I  could  relate  dozens  of  similar  cases  and  these 
have  convinced  me  that  somnoform  carefully  admin- 
istered with  an  abundance  of  air  seldom,  if  ever, 
nauseates. 

Blood  swallowed  nearly  always  produces  nausea, 
and  many  cases  of  nausea  during  or  after  somnoform 
anaesthesia,  in  operations  about  the  nose,  throat  and 
mouth,  are  caused,  not  from  the  anaesthetic,  but  from 
the  blood  that  gravitates  into  the  stomach. 

Headache,  with  me,  following  somnoform  anaesthe- 
sia, is  so  rare  that  it  is  hardly  worth  mentioning.  I 
have  only  known  three  or  four  patients  to  complain 
of  headache  after  somnoform  anaesthesia.  If  others 
have  more  of  these  cases,  they  probably  arise  from 
rebreathing  with  the  air  excluded. 


General  AncEsthetics  in  Dentistry.  207 


LECTURE  XVII. 
Somnoform  Administration. 

It  would  be  irksome  to  repeat  here  what  I  have  said 
in  a  previous  lecture  about  the  preparation  of  the  pa- 
tient, the  operating-chair,  the  assistant,  the  quiet  of  the 
room,  etc.,  yet  all  these  things  are  taken  for  granted 
in  what  I  shall  have  to  say  about  administering  som- 
noform. If  the  lecture,  "Elements  of  Success,"  has  not 
been  read,  let  me  suggest  that  this  lecture  be  deferred 
till  then,  because  what  I  am  to  say  now  about  admin- 
istering somnoform  can  not  be  successfully  accom- 
plished unless  the  details  already  referred  to  be  min- 
utely followed. 

There  are  several  ways  of  administering  somno- 
form, well  illustrated  by  the  following  narrative.  I 
gave  a  clinic  May,  1907,  before  the  Nebraska  State 
Dental  Society,  at  Lincoln.  A  gentleman  in  the  audi- 
ence evidently  thought  that  his  method  of  administer- 
ing somnoform  was  superior  to  mine,  because  he  asked 
me  if  I  would  permit  him  to  administer  somnoform  if 
he  procured  a  patient.  I  readily  consented.  He  went 
to  the  hotel  and  returned  with  a  traveling  salesman  of 
Jewish  nationality.  He  could  not  have  selected  a  much 
more  difficult  case.  The  patient  was  an  amusing  fel- 
low and  persisted  in  giving  a  history  of  the  case  in 
gpite  of  all  we  could  do  to  keep  him  cjuiet.    He  claimed 


208  General  Ancssthetics  in  Dentistry. 

to  live  in  San  Antonio,  Texas,  and  said  that  he  had 
been  in  every  dental  office  in  Texas  to  have  that  tooth 
extracted  and  he  had  never  met  a  man  before  who 
would  even  try  to  extract  it;  that  his  tooth  was  well 
known  in  Texas  and  they  all  advised  against  having 
it  out.  Examination  showed  the  tooth  to  be  an  un- 
erupted  upper  left  cuspid.  I  did  not  think  that  somno- 
form  was  the  anaesthetic  indicated  for  this  case.  Had 
it  come  to  me  in  private  practice,  the  patient  would 
have  been  sent  to  the  hospital  and  ether  administered. 
The  patient  was  made  ready  and  the  mouth-prop  in- 
serted. The  inhaler  used  was  the  de  Trey.  The  oper- 
ator placed  the  inhaler  over  the  nose  and  face  of  the 
patient,  then  took  from  the  box  a  5  c.  c.  capsule  of 
somnoform  and  placed  it  in  the  aperture  made  for 
that  purpose.  Then  he  started  his  patient  breathing  as 
deeply  as  you  ever  saw  any  one  breathe  in  your  life, 
and  after  he  was  breathing  rythmically,  just  as  he  ex- 
haled, the  dentist  fractured  the  somnoform  capsule 
and  excluded  all  air.  I  said  to  the  gentleman  next  to 
me,  "In  about  a  minute  you  will  see  something  inter- 
esting." In  less  than  a  minute  the  patient's  feet  were 
in  the  air,  he  knocked  the  inhaler  out  of  the  doctor's 
hands,  and  several  held  him  in  the  chair.  The  doctor 
was  about  to  begin  operating  when  I  grabbed  his  wrist 
and  asked  him  to  wait  a  moment.  I  assembled  the  ap- 
pliance which  in  the  skirmish  had  fallen  to  pieces,  and 
placed  it  over  his  face  again,  and  continued  the  anaes- 
thetic. In  the  meantime  he  had  taken  several  inhala- 
tions of  air,  was  breathing  about  normally  and  took 
the  somnoform  without  a  struggle  or  the  twitching  of 


General  Ancesthetics  in  Dentistry.  209 

a  muscle  of  his  face  and  1  put  him  down  very  deep  on 
account  of  the  nature  of  the  operation.  By  this  time 
the  doctor  was  cahu  again  and  in  about  two  minutes 
successfully  extracted  the  tooth,  and  the  patient  opened 
his  eyes  laughing  and  thought  he  was  at  the  hotel  rid- 
ing in  the  elevator.  He  went  over  to  the  hotel,  wrote 
out  a  description  of  the  case,  related  his  anaesthetic  ex- 
perience, subjectively  commended  the  anaesthetist  and 
the  operator  and  insisted  that  the  Nebraska  State  Den- 
tal Society  should  send  a  letter  of  greeting  to  the 
Texas  State  Dental  Society  and  inform  theiu  that  his 
tooth  had  been  captured. 

This  method  was  new  to  me,  and  it  may  have  been 
a  good  one,  but  we  came  very  nearly  having  a  double 
failure.  When  the  doctor  commenced  to  operate  the 
first  time,  the  patient  was  not  surgically  anaesthetized 
and  had  he  attempted  or  continued  to  extract  at  the 
time  I  requested  him  to  wait,  he  would  have  failed 
to  have  made  a  successful  extraction,  and  the  anaesthe- 
sia would  have  proven  a  decided  failure,  and  we  would 
have  had  a  rough  house.  I  say  the  method  was  a  new 
one.  The  new  feature  was  to  place  the  capsule  in  its 
aperture  and  have  it  remain  there,  the  inner  barrel 
being  held  forward  with  the  thumb.  The  deep  breath- 
ing and  shutting  off  all  air  after  the  rubber  bag  had 
been  inflated  was  adhering  strictly  to  the  directions 
furnished  with  somnoform  appliances  when  first  used 
in  America.  It  is  amazing  that  more  deaths  have  not 
occurred  from  somnoform,  and  the  only  thing  that  has 
prevented  them  is  the  remarkable  safety  of  the  anaes- 
thetic. 


210  General  Anoesthetics  in  Dentistry. 

Somnoform  is  the  easiest  of  all  anaesthetics  to  ad- 
minister. In  an  experience  of  some  eight  years,  and^ 
more  than  six  thousand  anaesthesias,  I  have  not  wit- 
nessed an  alarming  or  dangerous  symptom.  No  abso- 
lute rule  can  be  formulated  to  cover  all  cases  in  admin- 
istering an  anaesthetic,  as  the  personal  equation  must 
be  taken  into  consideration,  no  matter  what  anaesthetic 
agent  is  employed.  It  is  a  difficult  matter  to  explain 
on  paper  how  to  administer  an  anaesthetic.  It  is  an 
easy  matter  when  I  have  a  patient  in  the  chair,  be- 
cause the  method  is  adapted  to  that  particular  case  and 
those  looking  on  grasp  the  situation,  or,  if  they  do  not 
grasp  the  situation  or  understand  why  the  details  vary 
with  individual  cases,  it  can  be  explained  at  the  close 
of  the  anaesthesia. 

In  order  to  simplify  matters,  let  us  say  that  the 
patient  to  be  anaesthetized  is  a  woman  about  thirty 
years  of  age,  of  delicate  appearance,  weighing  about 
130  pounds,  anaemic,  of  quiet  demeanor,  the  operation 
being  the  extraction  of  an  upper  third  molar.  The 
tooth  is  not  a  very  difficult  one  to  extract.  We  have 
said  that  the  patient  is  anaemic,  and  this  is  the  keynote 
to  this  case.  You  can  anaesthetize  an  anaemic  patient 
a  little  more  rapidly  than  a  plethoric  patient  without 
discomfort. 

Exclusion  of  Air. — When  somnoform  was  first  in- 
troduced the  more  common  method  in  a  case  of  this 
kind  was  to  exclude  all  air  or  nearly  all  air.  The  pa- 
tient is  seated  in  the  chair,  mouth-prop  in  position. 
She  is  instructed  to  breathe  rather  deeply.  Fracture 
the  somnoform  twbe  before  adjusting  the  inhaler.    If 


General  Anesthetics  in  Dentistry.  211 

the  capsule  is  fractured  when  the  inhaler  is  in  posi- 
tion on  the  face,  the  report  is  apt  to  startle  the  patient. 
The  patient  is  still  breathing  as  described.  Place  the 
inhaler  again  over  the  nose  and  face,  just  as  she  be- 
gins to  exhale,  and  that  exhalation  will  go  into  and 
inflate  the  bag.  The  valve  is  so  adjusted  that  the  pa- 
tient gets  about  one-third  somnoform  and  two-thirds 
air.  Or  all  air  can  be  excluded  and  patient  then  in- 
hales pure  somnoform  with  only  the  air  which  was 
exhaled  into  the  bag.  With  a  3  c.  c.  capsule  it  only 
requires  about  three  or  four  inhalations  to  induce  a 
sufficiently  deep  anaesthesia  for  the  kind  of  a  case  we 
are  now  discussing.  In  fifteen  to  thirty  seconds  the 
patient  can  be  anaesthetized  by  this  method. 

I  do  not  believe  that  this  method  should  be  used 
in  routine  work.  The  anaesthetic  effect  is  not  as 
pleasant  to  the  patient ;  the  anaesthesia  induced  is 
nearly  always  more  profound  than  is  necessary;  the 
patient  is  more  apt  to  create  a  disturbance  in  the  begin- 
ning and  be  nauseated  afterwards;  and  it  is  certainly 
more  dangerous  than  the  method  which  I  will  next  de- 
scribe. 

Admission  of  Air. — The  mouth-prop  is  in  position 
and  the  patient  is  ready  to  be  anaesthetized.  Fracture 
a  3  c.  c.  somnoform  capsule  in  the  capsule  chamber. 
Say  nothing  about  the  breathing  in  the  beginning. 
Place  the  inhaler  over  the  nose  and  mouth.  After  two 
or  three  inhalations  with  all  anaesthetic  excluded,  re- 
lease valve,  gradually  admitting  more  and  more  som- 
noform, then  one  or  two  inhalations  with  all  air  ex- 
cluded.     With   some   patients   it   is   not   necessary    to 


212  -     General  Anccsthetics  in  Dentistry. 

exclude  all  air.  If  a  deeper  anaesthesia  is  desired,  more 
inhalations  can  be  taken  with  the  air  excluded.  If 
the  patient  breathes  normally,  do  not  interrupt  her.  If 
she  breathes  too  deeply  or  not  deeply  enough,  then  in 
a  quiet,  firm  voice  command  or  suggest  the  degree  of 
respiration  you  desire.  Anaesthesia  thus  induced  is 
much  more  agreeable  to  the  patient,  there  is  rarely 
struggling  or  excitement,  nausea  seldom  occurs,  and 
supervening  headache  is  almost  unknown.  Circulatory 
disturbance  is  less  marked  than  when  all  air  is  ex- 
cluded, and  it  is  certainly  much  safer,  especially  with 
elderly  people  with  brittle  arteries. 

Just  at  this  stage  we  will  assume  that  instead  of 
one  tooth  this  patient  has  half  a  dozen  teeth  to  be  re- 
moved. The  patient  has  had  but  one  or  two  inhala- 
tions, we  will  say,  with  all  air  excluded.  Now  hold 
your  ear  very  close  to  the  face  piece.  You  will 
hear,  by  the  time  two  or  three  more  inhalations  have 
been  taken,  a  little  low  purring  sound.  This  is  caused 
by  relaxation  of  the  soft  palate,  and  comes  with  a 
little  deeper  anaesthesia  than  is  usually  necessary  to 
relax  the  arm  muscles.  Let  me  add  here,  that,  when 
this  gentle  snoring  sound  is  heard,  I  believe  the  pa- 
tient is  as  deeply  anaesthetized  as  is  necessary  for  any 
surgical  operation,  and  to  anaesthetize  longer  is  to  over- 
anaesthetize  the  patient  without  getting  a  more  pro- 
found anaesthesia. 

For  extracting  cases,  when  light  snoring  is  heard, 
remove  the  inhaler  (Stark)  or  evert  the  mouth  cover 
with  the  DeFord  inhaler  and  begin  to  operate.  When 
other  operations  are  to  be  performed,  other  than  mouth 


General  Ancesthetics  in  Dentistry.  213 

operations,  at  this  stage  of  the  anaesthesia,  remove  the 
inhaler  or  open  the  valve  for  in  inhalation  or  two  of 
air,  then  replace  it  and  proceed  as  you  would  with 
chloroform  or  ether.  In  this  way,  I  kept  a  patient 
under  the  influence  of  somnoform  for  twenty-five 
minutes. 

For  an  easy  extraction,  it  is  not  necessary  to  push 
the  anaesthetic  far  enough  for  snoring. 

Let  us  suppose  that  our  anaemic  patient,  after  tak- 
ing two  or  three  inhalations  of  somnoform  is  getting 
approximately  one-third  somnoform  and  two-thirds 
air,  should,  through  dread  or  apprehension,  become  a 
trifle  nervous  and  move  the  hands  and  feet,  I  would 
shut  off  nearly  or  quite  all  air  and  anaesthetize  the 
patient  quickly.  This  seldom  happens,  but,  when  it 
does,  I  induce  a  quick  anaesthesia. 

Our  next  patient  is  a  plethoric  one  about  thirty 
years  of  age,  medium  height,  weighing  about  150 
pounds,  for  whom  it  is  necessary  to  extract  a  lower 
left  second  molar.  We  have  said  that  this  patient  is 
plethoric,  and  this  is  the  keynote  of  this  case.  We 
have  this  time  to  deal  with  a  red-faced,  full-blooded 
patient. 

We  have  already  shown  that  the  blood  flows  a  little 
more  rapidly  as  the  result  of  somnoform  adminis- 
tration, and  in  plethoric  people,  as. a  rule,  I  admit 
more  air  in  the  beginning  than  when  anaesthetizing 
anaemic  patients.  If  all  air  is  excluded  from  the  very 
start,  these  patients  are  apt  to  become  excited.  The 
circulation  starts  up  too  rapidly  and  increased  circula- 
tion causes  a  feeling  of  fullness  in  the  head,  roaring 


214  General  Anccsthefics  in  Dentistry. 

and  unpleasant  noises  are  heard  and  we  have  a  con- 
dition more  like  that  produced  by  nitrous  oxid.  The 
patient  becomes  distressed  before  becoming  anaesthet- 
ized, and  the  dream  experienced  is  not  a  pleasant  one, 
as  a  rule,  if  the  air  is  insufficient  or  excluded  in  the 
beginning. 

The  mouth-prop  is  adjusted  and  the  patient  is 
ready  and  the  inhaler,  the  Stark,  is  in  position.  For 
the  first  three  or  four  inhalations  exclude  all  somno- 
form,  admit  air  only,  then  gradually  admit  more  and 
more  somnoform.  If  the  case  is  not  very  difficult  and 
the  extraction  can  be  made  quickly,  it  may  not  be  nec- 
essary to  exclude  all  air,  but  if  the  case  is  difficult,  one 
or  more  inhalations  with  all  air  excluded  may  be 
necessary.  You  have  now  simply  to  watch  your 
patients  for  anaesthetic  symptoms  and  proceed  from 
now  on  just  as  with  the  anaemic  patient.  These  pleth- 
oric patients  can  be  anaesthetized  just  as  quickly  as 
anaemic  patients,  but  I  always  take  a  little  more  time 
with  the  former  and  am  satisfied  that  I  am  well  repaid 
for  using  a  little  slower  method. 

I  tested  the  Stark  inhaler  for  more  than  a  year 
before  mentioning  it  in  a  dental  journal  or  using  it  at 
a  dental  meeting.  I  described  it  in  the  Dental  Brief 
for  December,  1907,  and  gave  a  talk  and  demonstration, 
December  4th,  '07,  before  the  junior  medical  class  and 
the  senior  and  junior  dental  classes  of  the  Colleges  of 
Medicine  and  Dentistry,  State  University  of  Iowa, 
anaesthetizing  a  dozen  students  selected  by  the  profes- 
sor of  materia  medica  of  such  temperaments  and  patho- 
logical conditions  as  he  wished  anaesthetized  for  the 


General  Anesthetics  in  Dentistry.  215 

benefit  of  the  class.  Just  a  year  previously  I  anaes- 
thetized Prof.  Chase  and  three  of  his  medical  students, 
with  the  de  Trey  inhaler,  within  a  period  of  fifteen 
minutes,  and  in  ten  minutes  after  anaesthetizing  Prof. 
Chase  he  was  lecturing  to  another  class. 

Let  us  select  this  time  a  nervous  little  black-haired, 
sallow  patient  given  to  hysteria,  one  that  insists  she 
knows  she  can  not  take  "the  stuft"'  because  she  will  die. 
She  also  knows  that  it  will  nauseate  her,  and  that  she 
will  have  an  awful  dream,  etc.  These  patients  become 
very  nervous,  usually,  before  taking  the  first  inhala- 
tion, and,  if  the  first  inhalation  is  strong,  they  go  all 
to  pieces. 

This  patient  has  the  teeth  properly  held  apart,  the 
inhaler  is  in  position  and  the  patient  begins  to  inhale. 

This  patient  is  studying  the  effect  very  closely  and 
will  rebel  at  the  slightest  provocation.  With  the  Stark 
or  De  Ford  inhaler,  you  can  have  her  breathe  for  five 
minuteSs  if  you  wish,  and  the  patient  will  not  get  so 
much  as  an  unpleasant  odor.  All  this  time  you  can  be 
suggesting  that  the  anaesthetic  is  not  the  least  bit  dis- 
agreeable, that  the  odor  is  mild  and  pleasant,  and  when 
you  are  ready  you  can  admit  just  a  trace.  By  this  time, 
the  patient  is  calmed,  thinks  there  is  nothing  disagree- 
able about  it,  and,  by  gradually  admitting  a  little  more 
at  a  time,  it  steals  so  quietly  over  the  mucous  mem- 
brane into  the  lungs  that  the  patient  is  anaesthetized 
before  she  knows  it,  without  a  struggle.  I  have  accom- 
plished this  scores  of  times,  with  patients  that  gave 
every  evidence  of  a  most  unsatisfactory  anaesthesia. 
Yesterday  I  operated  for  a  little  red-headed  girl  of 


216  General  Anaesthetics  in  Dentistry, 

seven  years  of  age.  She  was  very  brave  till  I  placed 
the  mouth-prop  in  position,  then  she  lost  all  control  of 
herself  and  it  looked  like  a  defeat.  I  placed  the  inhaler 
over  her  mouth  and  she  held  her  breath.  I  knew  she 
could  not  hold  her  breath  forever,  and  the  longer  she 
held  it  the  deeper  would  be  the  next  inhalation.  The 
inhaler  was  over  her  mouth  and  a  physician  and  her 
father  held  her  hands.  When  she  started  to  exhale,  I 
turned  on  about  ten  per  cent,  of  somnoform,  which 
went  into  her  lungs  with  that  first  deep  inhalation. 
The  same  amount  the  second  time;  the  third  time,  I 
only  admitted  about  half  as  much  somnoform,  for  she 
was  breathing  very  deeply.  One  more  inhalation  of 
about  five  per  cent,  of  somnoform  was  all  she  needed, 
and  I  made  a  successful  extraction  of  a  sixth-year 
molar  in  a  state  of  acute  alveolar  abscess  too  badly 
broken  down  to  save.  You  can  control  the  amount  of 
somnoform  desired  for  a  given  case  absolutely  with  the 
Stark  or  De  Ford  inhaler. 

I  could  have  held  the  inhaler  over  the  mouth  of 
this  patient  till  she  resumed  normal  breathing,  had  I 
so  desired,  without  the  little  girl  inhaling  a  bit  of 
somnoform,  but  she  was  growing  more  nervous,  of 
course,  all  the  time,  and  I  was  so  sure  of  my  appliance 
that  I  felt  no  alarm  whatever.  I  could  not  have  made 
this  fine  adjustment  with  any  other  appliances  with 
which  I  am  familiar. 

When  speaking  of  nausea,  I  referred  to  a  young 
lady  whose  stomach  was  so  delicate  that  the  odor  of 
meat  being  broiled  or  fried  was  sufficient  to  nauseate 
her.    Her  mother  called  me  to  one  side  and  explained 


General  AncFsthetics  in  Dentistry.  21? 

this  before  I  administered  the  anaesthetic,  thinking  she 
might  become  sick  before  I  had  time  to  begin  the 
operation.  I  knew  this  young  lady  had  to  be  handled 
very  carefully  or  we  would  be  defeated  and  fail  to  make 
the  extraction.  1  was  as  careful  in  this  case  as  with 
the  hysterical  patient  previously  described.  I  excluded 
somnoform  for  a  period  of  a  minute  or  two,  allowing 
only  air  to  pass  through  the  inhaler  till  I  had  the 
patient's  confidence,  keeping  up  the  suggestion  that 
there  was  nothing  unpleasant  about  it,  then  turned  on 
just  a  trace  of  somnoform,  and  continued  this  for  thirty 
to  forty  seconds,  then  just  a  little  more  for  nearly  as 
long.  I  knew  now  that  the  olfactory  nerve  was  suffi- 
ciently anaesthetized  not  to  take  cognizance  of  the  odor, 
and  gave  her  two  inhalatix^ns  without  air,  and  the 
anaesthesia  induced  was  all  I  needed.  I  made  a  suc- 
cessful operation  and  no  nausea  resulted.  I  may  have 
had  patients  as  sensitive  to  odors  as  this  one,  but,  if 
they  were,  it  was  not  so  thoroughly  explained  to  me, 
and  I  did  not  realize  the  situation  as  in  this  case. 


318  General  Anccsthetics  in  Dentistry. 


LECTURE  XVIII. 

Somnoform  Administrations — Continued. 

I  have  learned  by  experience  that  patients  coming 
from  the  farm  and  those  leading  outdoor  lives  do  not 
stand  deprivation  of  oxygen  to  the  same  degree  with- 
out discomfort  as  those  who  lead  a  more  sedentary  life. 
Clerks  in  stores,  bookkeepers,  housewives,  and  the  like, 
whose  work  necessitates  long  hours  indoors,  can  be 
anaesthetized  comfortably  with  less  oxygen  than  those 
that  spend  much  time  out  of  doors.  I  think  that  this 
statement  will  account  for  some  of  the  cases  that  have 
been  reported  to  me  by  others  in  which  the  patient 
became  excited  and  made  a  disturbance.  Too  much 
somnoform  was  administered  in  the  very  beginning 
and  not  a  sufficient  amount  of  air.  The  circulation  and 
blood  pressure  being  suddenly  augmented,  the  patient 
becomes  violently  stimulated  and  excited  rather  than 
anaesthetized,  and  the  effect  is  much  the  same  as  that 
produced  by  ether  in  the  stimulation  stage.  Many 
patients  have  to  be  held  down  during  this  stage  in 
ether  administration,  and  many  more  would  make  dis- 
turbances in  hospital  practice  but  for  the  fact  that 
they  are  strapped  to  the  table  in  advance,  and  ether 
anaesthesias,  that  to  all  outward  appearances  are  calm 
and  without  a  struggle,  are  so  only  because  the  patient 
can  not  move. 


General  AnastJictics  in  Dentistry.  219 

We  have  this  same  condition  in  nitrous  oxid,  but  it 
occurs  much  more  frequently  than  in  somnoform.  We 
find  it  present  in  a  much  less  degree  in  chloroform  than 
in  ether.  We  have  less  of  it  in  somnoform  than  with 
any  other  anaesthetic  with  whicli  I  am  acquainted.  In 
all  stages  of  anaesthesia,  from  first  to  last,  we  may  say, 
nitrous  oxid  is  to  ether  what  somnoform  is  to  chloro- 
form. In  the  matter  of  excitability,  we  may  arrange 
them  in  the  following  order:  ether,  nitrous  oxid,  chlo- 
roform, ethyl  chloride  and  somnoform. 

In  my  own  practice,  I  have  never  had  a  case  in 
which  the  disturbance  has  been  of  sufficient  impor- 
tance to  relate.  Perhaps  this  is  so  from  the  fact  that  I 
never  attempt  to  restrain  a  patient.  There  is  a  stage 
just  before  consciousness  returns  when  patients  are 
almost  but  not  quite  awake,  in  which  they  are  greatly 
mystified  and  they  do  not  know  where  they  are  or  what 
they  are  doing  or  what  is  being  done  to  them.  This  is 
the  time  in  my  practice  when  I  insist  on  everybody  in 
the  room  remaining  absolutely  quiet.  Do  not  shake 
the  patient,  or  tell  him  to  lean  forward  or  thrust  the 
cuspidor  under  his  chin  and  call  to  him  to  spit.  Place 
napkins  in  the  mouth  as  already  explained  to  absorb 
the  blood  and  allow  the  patient  to  awake  as  from 
natural  sleep.  If  his  dream  happens  to  be  an  unpleas- 
ant one  and  he  should  misinterpret  your  pushing  him 
forward  and  shaking  him  for  the  attack  of  the  villain 
he  sees  in  his  dream,  he  may  feel  called  upon  to  defend 
himself,  and  you  have  a  fight  on  your  hands. 

The  following  case  is  the  most  pronounced  of  its 
kind  that  has  ever  come  under  my  personal  observ- 


220  General  Anccsthetics  in  Dentistry. 

ation :  The  patient  was  referred  for  the  extraction  of  a 
lower  right  third  molar.  As  soon  as  I  saw  him,  it 
occurred  to  me  that  this  man  would  make  trouble.  In 
size  he  was  about  five  feet  six  inches  in  height 
and  would  weigh  probably  two  hundred  pounds.  I 
inquired  if  he  had  ever  taken  an  ansesthetic.  He 
informed  me  that  he  had  about  a  year  previously,  at 
the  hospital,  and  that  it  took  all  the  doctors  and  nurses 
in  the  institution  to  hold  him.  He  ventured  the  opin- 
ion that  the  ansesthetic  I  proposed  using  "could  not 
put  him  to  sleep."  We  made  him  ready  for  the  anses- 
thetic, and  I  motioned  to  the  assistant  to  stand  well 
back,  lest  he  should  strike  her  suddenly  and  without 
warning,  with  his  fist.  I  had  a  friend  knocked  stiff  on 
one  occasion  by  just  such  a  patient,  when  administer- 
ing nitrous  oxid  gas.  The  patient  inhaled  as  instructed, 
and  I  thought  him  almost  ready  for  the  operation ;  I 
lifted  his  hand  to  test  his  muscles,  and  there  was  where 
I  made  my  mistake.  Two  inhalations  more  would 
have  placed  him  beyond  recognizing  any  physical  dis- 
turbance. I  disturbed  his  consciousness,  and  he  said, 
"Come  on,  fellows;  let's  get  right  after  them."  He 
was  on  his  feet  in  a  moment,  grabbed  the  towel  from 
his  neck,  opened  tjie  door  into  the  reception  room,  put 
on  his  hat,  went  out  into  the  hall,  and  just  as  he  was 
entering  the  reception  room  of  my  neighbor,  conscious- 
ness returned.  I  walked  along  with  him,  telling  him 
to  be  in  no  hurry,  "Just  wait  a  moment,"  but  not 
restraining  him  in  the  least.  We  walked  back  together, 
he  inquired  if  I  removed  the  tooth  or  if  he  made  any 
disturbance,  put  on  his  hat,  and  said:    'T  will  try  it 


General  Anesthetics  in  Dentistry.  221 

again  another  clay."  This  man  impressed  me  as  being 
an  alcoholic.  He  would  not  have  tolerated  restraint. 
It  would  have  been  a  mistake  to  have  tried  to  force  him 
to  inhale  more  of  the  somnoform. 

All  other  cases  in  which  there  has  been  undue  excite- 
ment as  the  result  of  somnoform  administration,  in 
my  practice,  have  occurred  after  the  induction  of  anaes- 
thesia and  after  the  patient  has  been  operated  upon. 

I  recall  a  case  of  this  kind.  At  the  close  of  the 
anaesthesia,  the  patient  grabbed  his  right  side  pocket 
with  both  hands,  holding  it  tenaciously.  I  did  not  try 
to  interfere  with  him  ;  had  I  done  so,  I  probably  would 
have  been  roughly  handled.  In  the  course  of  a  few- 
seconds,  he  realized  his  actions  and  laughed  heartily. 
I  said,  "What  kind  of  a  dream  did  you  have?"  He 
replied,  "1  have  $400  in  that  pocket,  and  I  thought 
some  one  was  trying  to  rob  me."  Had  I  undertaken 
to  hold  this  man  in  the  chair,  or  restrained  him,  he 
would  have  resisted  violently. 

Another  case :  A  large  man  over  six  feet  tall  and 
well  proportioned,  at  the  conclusion  of  an  extraction, 
said,  "Let  me  out  of  here."  I  stepped  aside  and  let  him 
leave  the  chair.  He  picked  up  his  hat  and  walked  to 
the  door  leading  from  the  private  room  to  the  hall. 
Finding  the  door  locked,  he  turned  and  just  then 
regained  consciousness,  and  said,  "What  am  I  doing 
here?  Oh,  yes;  I  was  having  a  tooth  out.  Did  you 
get  it?"  This  man  was  a  pronounced  alcoholic.  His 
physician  accompanied  him  to  the  office,  fearing  a  dis- 
turbance, which  we  would  have  undoubtedly  had  if  an 
attempt  had  been  made  to  restrain  him. 


222         '      General  Anesthetics  in  Dentistry. 

The  following  case  was  reported  to  me,  October  15, 
1907,  by  Dr.  Z.  T.  Roberts,  of  Rocky  Ford,  Colo.,  with 
permission  to  use  it: 

"A  farmer,  about  forty  years  of  age,  presented  for 
seven  extractions.  He  took  somnoform  nicely,  and  I 
took  out  all  the  teeth.  He  slept  on  for  probably  a 
minute  and  a  half,  when  he  suddenly  shouted  "Whoa !" 
at  the  top  of  his  voice  several  times,  and  tried  to  get 
out  of  the  chair.  I  pulled  him  back  into  the  chair,  and 
held  him,  whereupon  he  began  to  curse  me  and  strug- 
gled to  get  out.  Finally  he  broke  loose,  and,  raving 
like  a  madman,  faced  me.  At  this  time  his  reason 
returned,  probably  through  recognizing  me,  and  he 
quieted  at  once.  This,  I  suppose,  was  merely  a  freak 
of  anaesthesia,  and  not  uncommon  with  any  anaes- 
thetic ;  however,  it  is  the  only  case  of  the  kind  I  have 
ever  had,  and  I  have  been  giving  it  about  two  years. 
I  have  given  it,  probably,  about  five  hundred  times." 

This  man  was  driving  his  horses  and  evidently  did 
not  wish  to  be  disturbed,  and,  had  the  doctor  not  tried 
to  restrain  him,  he  probably  would  have  awakened  in 
a  pleasant  frame  of  mind. 

This  Rocky  Ford  case  reminds  me  of  the  delightful 
time  I  had  in  June,  1907,  at  Colorado  Springs,  where  I 
attended  a  meeting  of  the  Colorado  State  Dental 
Society.  During  my  talk  before  the  society,  I  had 
mentioned  that  somnoform  is  non-irritating  to  the 
mucous  membrane  or  air-passages,  being,  for  that  rea- 
son, a  most  excellent  anaesthetic  in  all  bronchial  or  pul- 
monary conditions.  At  the  close  of  my  remarks,  a 
dentist  came  to  me  and  told  me  that  he  was  a  great 


General  Anarsthetics  in  Dentistry.  223 

sufferer  from  asthma.  He  said  that  many  nights,  not 
being  able  to  recline,  he  was  compelled  to  sit  in  a  chair 
all  night.  He  was  compelled  to  stay  in  a  high  altitude, 
then  being  a  resident  of  Victor,  Colo.,  which  has  an 
altitude  of  more  than  10,000  feet.  He  had  listened  with 
great  interest  to  what  1  had  been  saying,  and  recjuestcd 
me  to  anaesthetize  him  privately,  lest  through  nervous- 
ness or  coughing  he  would  cause  me  to  make  a  failure 
of  my  demonstration.  I  asked  him  if  this  was  his  only 
reason  for  desiring  a  private  ansesthetization,  and  he 
assured  me  that  it  was.  I  told  him  not  to  hesitate  for 
a  moment ;  that  he  would  have  the  most  comfortable 
and  refreshing  sleep  that  he  had  experienced  in  years. 
I  placed  him  on  a  couch  and  in  about  forty-five  seconds 
he  was  sleeping  beautifully.  I  am  sure  those  present 
will  never  forget  his  many  expressions  of  delight.  He 
stated  time  and  again  that  he  had  not  experienced  such 
a  sense  of  comfort  since  his  boyhood  days. 

Dr.   B ,  another  dentist,  informed  me  that  he 

had  remained  in  that  high  altitude  until  he  had  become 
a  nervous  wreck.  He  expressed  a  desire  to  be  anaes- 
thetized, doubling  that  one  in  his  nervous  condition 
could  be  successfully  anaesthetized  with  somnoform. 
I  assured  him  that  he  could  be  as  comfortably  anaesthe- 
tized as  the  gentleman  with  the  asthma.  The  predic- 
tion proved  to  be  true. 

Some  months  since,  I  met  a  friend  on  the  street — 
a  physician — and  in  the  course  of  conversation  he  told 
me  that  his  wife  had  been  suffering  with  her  teeth,  and 
that  it  was  necessary  to  have  four  of  them  extracted, 
but  on  account  of  her  impaired  physical  condition  the 


234  General  Anesthetics  in  Dentistry. 

operation  had  been  delayed  from  time  to  time.  This 
lady  is  one  of  the  most  delicate  women  I  have  ever 
known.  About  a  year  previously,  while  undergoing 
an  appendectomy,  she  experienced  an  anaesthetic  col- 
lapse and  for  two  hours  remained  in  a  critical  condi- 
tion. With  such  a  history,  her  husband  was  appre- 
hensive as  to  the  outcome  of  an  anesthesia  induced  for 
the  removal  of  these  teeth,  yet  agreed  with  me  that  it 
would  be  equally  hazardous  to  extract  the  teeth  with- 
out employing  an  anaesthetic.  I  explained  to  him  the 
physiological  action  of  somnoform,  and  we  decided  to 
operate  on  the  following  morning.  The  patient  is  a 
nervy  little  woman,  and  arrived  at  the  appointed  hour, 
cheerful  and  buoyant  in  spirits,  and  I  knew  that,  in 
such  a  frame  of  mind,  she  could  be  successfully  anaes- 
thetized. The  husband  had  worried  all  night,  and  was 
alarmed  lest  an  accident  might  occur.  I  suggested 
that,  at  a  signal  from  me,  he  should  place  his  finger 
on  the  radial  artery,  and  if  he  discovered  the  slightest 
indication  of  approaching  danger  to  nod  his  head,  and 
I  would  discontinue  the  anaesthetic.  I  did  not  wish 
the  patient  to  feel  that  we  were  in  the  least  apprehen- 
sive about  her  condition,  and  for  that  reason  did  not 
signal  the  doctor  to  take  her  pulse  until  she  had  inhaled 
sufficient  somnofbrm  to  dull  her  sensibilities.  I  lifted 
my  eyes  every  second  or  two,  from  the  patient  to  her 
husband,  but  he  gave  no  signal.  I  lifted  her  hand ;  it 
dropped,  showing  muscular  relaxation.  I  removed  the 
teeth,  the  patient  slept  quietly  for  about  thirty  seconds, 
a  smile  lit  up  her  countenance,  and  developed  into  an 
odd  little  laugh,  peculiar  to  her,  and  in  five  minutes 


General  AnccstJictics  in  Dentistry.  325 

she  was  out  of  the  office,  on  her  way  home.  The 
amount  of  somnoform  used  in  this  case  was  not  over 
one  cubic  centimeter  with  abundant  admixture  of  air. 
It  is  a  very  easy  matter  to  over-anaesthetize  a  patient, 
and  that  was  what  happened  in  the  case  of  the  patient 
under  consideration  on  a  previous  occasion.  I  have 
had  a  number  of  these  cases,  in  which  the  family  physi- 
cian refused  to  achninister  an  anaesthetic  on  account  of 
an  impaired  physical  condition,  that  have  taken  somno- 
form as  successfully  as  the  wife  of  my  friend,  the 
physician. 

There  is  a  condition  of  analgesia  following  som- 
noform anaesthesia  that  is  valuable  to  the  dental  sur- 
geon. After  the  patient  is  perfectly  conscious  and  has 
freed  the  mouth  from  blood,  there  is  a  period  of  several 
seconds  in  which  considerable  can  be  done.  Some- 
times, in  rapid  extracting,  where  a  number  of  teeth  and 
roots  are  to  be  removed,  the  blood  so  interferes  with 
vision  that  some  of  the  roots  are  overlooked,  others 
are  loosened  but  remain  in  their  sockets,  and  some- 
times pieces  of  process  should  be  removed.  There  are 
some  patients  who  think  they  are  being  hurt  if  they 
know  something  is  being  done.  This  analgesic  stage 
is  of  no  practical  value  to  such  patients.  But  there 
are  other  patients  who  will  jiermit  you  to  operate  if 
"they  do  not  feel  pain.  With  this  class  you  can  remove 
such  roots  as  I  have  mentioned  and  they  will  feel  no 
pain  whatever. 

Do  not  misunderstand  me,  please.  I  believe  in 
operating,  primarily,  while  the  patient  is  unconscious 
and  to  cease  in  time  so  that  no  pain  shall  be  experi- 


226  General  Ancssthetics  in  Dentistry. 

enced.  Be  sure  and  do  that.  If  there  is  any  little  thing 
to  be  done  during  this  analgesic  stage,  it  should  be 
done  with  the  full  consent  and  knowledge  of  the 
patient,  with  the  understanding  that  you  will  desist 
if  he  finds  he  is  being  hurt. 

I,  with  others,  have  recognized  this  analgesic  stage, 
but  I  did  not  appreciate  the  extent  to  which  it  might  be 
used  until  I  was  called  on  one  occasion  to  administer 
somnoform  to  an  elderly  lady  for  the  amputation  of  a 
finger.  I  had  used  a  3  c.  c.  capsule  of  somnoform  in 
the  de  Trey  inhaler,  and  noticed  that  my  patient  was 
returning  to  consciousness  and  I  asked  the  surgeon 
if  I  should  fracture  another  tube.  He  replied  that  it 
would  not  be  necessary  as  he  was  almost  through,  and 
only  had  two  more  stitches  to  take.  Just  then  the 
patient  opened  her  eyes  and  remarked,  "I  am  alive, 
ain't  I,  doctor,  thank  God."  I  assured  her  that  she 
was  certainly  alive.  Then  she  turned  to  the  surgeon 
and  said,  "Whose  finger  is  that  you  are  working  on?" 
He  replied,  "Yours."  "Oh,  no,"  she  said,  "that's  not 
my  finger,"  and  she  pulled  back  her  arm,  and  said, 
"Why,  yes,  it  is ;  ain't  that  funny !  You  are  not  hurting 
me  one  bit." 

It  is  well  that  we  have  this  analgesic  stage  in  den- 
tal operations  for  the  following  reason :  in  cases  of 
acute  pericementitis  and  alveolar  abscess  and  all  those 
cases  in  which  considerable  force  is  exerted,  the  pain 
does  not  discontinue  the  moment  the  tooth  or  root  is 
extracted,  and  the  after-pain  is  concealed  for  a  while, 
or  until  it  subsides  in  a  large  measure,  or  completely. 
With  nitrous  oxid,  we  do  not  have  this  period  of  anal- 


General  Anesthetics  in  Dentistry.  237 

gesia,  and  patients  who  have  been  anaesthetized  fre- 
quently insist  that  they  have  been  severely  hurt,  and 
felt  as  much  pain  as  though  they  had  not  taken  the 
gas.  I  believe  very  many  times  it  is  this  post-operative 
pain  that  is  felt  under  nitrous  oxid,  and  not  the  actual 
pain  of  operating. 

Yesterday  a  dentist  brought  a  patient  to  me  to 
have  extracted  a  lower  left  third  molar  tooth.  This 
patient  also  had  an  upper  right  second  molar,  contain- 
ing a  dead  pulp,  that  was  so  sore  that  she  could  not 
stand  the  pressure  of  instruments  to  open  into  the  pulp 
chamber.  The  dentist  requested  me  to  open  the  pulp 
chamber  under  somnoform  after  removing  the  tooth. 
I  explained  to  the  patient  this  stage  of  analgesia,  and 
I  promised  her  that  she  would  not  be  hurt,  although 
she  would  probably  know  when  I  drilled  into  the  tooth. 
I  anaesthetized  the  patient  with  somnoform,  extracted 
the  third  molar,  shifted  the  mouth-prop,  opened  into 
the  pulp  chamber  without  pain  or  annoyance  to  the 
patient. 

When  the  nervous  system  has  become  disordered 
by  the  use  of  tobacco,  chloral,  alcoholic  indulgence, 
morphine  or  other  narcotics,  patients  usually  exhibit 
abnormal  symptoms  during  or  after  anaesthetization. 
These  conditions,  no  doubt,  explain  abnormalities  autl 
account  for  the  action  of  some  individuals  that  other- 
wise might  remain  a  mystery.  Morphine  is  often  in- 
jected shortly  before  administering  an  anaesthetic  to 
deepen  and  prolong  the  anaesthesia,  but  those  addicted 
to  the  use  of  morphine  are  sometimes  rendered  almost 
immune  to  an  anaesthetic.     Dr.  R.  J.  Carter  furnished 


228  General  Anccsthetics  in  Dentistry. 

Hewitt,  of  London,  an  account  of  a  case  in  which  the 
patient,  a  morphiomaniac,  was  an  hour  and  three-quar- 
ters being  anaesthetized,  and  eight  ounces  of  chloro- 
form were  expended.  I  mention  this  as  a  matter  of 
interest,  as  it  may  serve  as  an  explanation,  should  you 
in  your  anaesthetic  practice,  on  some  occasion,  fail  to 
produce  narcosis. 

Alcoholics  are  always  dreaded,  no  matter  what 
anaesthetic  agent  is  employed.  I  have  experienced  very 
little  difficulty,  however,  with  alcoholics  when  admin- 
istering somnoform.  I  have  had  a  number  of  narrow 
escapes  with  nitrous  oxid  and  became  suspicious  of 
any  person  that  smelled  of  liquor.  My  rule  with  ni- 
-  trous  oxid  has  been  to  postpone  the  operation  if  I 
detected  the  odor  of  liquor  on  the  breath.  I  also 
adopted  this  rule  with  somnoform,  and  adhered  to  it 
strictly  for  two  years.  One  day  I  was  summoned  by 
'phone  to  administer  somnoform  for  a  finger  amputa- 
tion. When  I  arrived,  I  found  a  man  who  had  caught 
his. finger  in  a  sausage  machine  and  crushed  it  so 
badly  as  to  necessitate  amputation.  This  patient  had 
taken  several  drinks  of  whisky  and  was  partially  in- 
toxicated. I  did  not  know  how  successful  I  might  be 
with  somnoform.  but  there  was  nothing  else  to  do.  I 
decided  that  I  would  make  as  cpiick  an  anaesthesia  as 
possil:)le,  and  give  him  no  time  in  which  to  become  ex- 
cited. I  had  him  snoring  in  thirty  seconds  and  he  never 
so  much  as  disturbed  a  muscle  of  his  body.  Thus 
deeply  anaesthetized,  I  admitted  two  inhalations  of 
pure  air,  and  after  that  I  permitted  him  to  take  one 
inhalation  from  the  inhaler  and  two  inhalations  of  air 


General  Anccsthetics  in  Dentistry.  229 

throughout  anaesthesia.  There  was  no  excitement, 
whatever,  either  during  or  after  the  anaesthesia.  This 
experience  excited  my  curiosity,  and  I  determined  that 
in  the  future  I  would  not  refuse  to  anaesthetize  a  patient 
because  of  the  fact  he  had  taken  a  drink.  Since  then 
I  have  refused  no  patient  on  that  account,  and  I  have 
had  no  occasion  to  regret  so  doing.  It  has  been  my 
privilege  to  anaesthetize  many  pronounced  alcoholics. 
I  recall  now  the  case  of  one  of  the  most  pronounced 
alcoholics  in  this  State.  This  man  was  referred  for  the 
extraction  of  an  upper  third  molar  on  the  right  side. 
I  admitted  an  abundance  of  air  along  with  the  somno- 
form  in  the  beginning  of  the  administration,  and  as  it 
commenced  to  take  effect,  he  said,  "For  Christ's  sake, 
don't  begin  yet,"  and  commenced  to  lean  forward.  I 
held  the  inhaler  over  his  face,  but  made  no  attempt  to 
restrain  him.  By  the  time  he  was  ready  for  the  opera- 
tion, his  head  was  far  enough  forward  to  rest  his  chin 
on  his  knees.  I  got  down  on  one  knee  and  did  the 
extrasting.  All  this  time  he  was  repeating  the  sentence 
quoted  above,  and  said  it  ten  or  twelve  times  after  the 
tooth  had  been  removed.  In  about  a  minute  he  sat 
upright  in  the  chair,  expressed  himself  as  having  ex- 
perienced no  pain,  and  was  surprised  to  know  that  tl:e 
tooth  was  out.  It  is  said  to  be  difficult  and  sometimes 
impossible  to  secure  total  muscular  relaxation  in  alco- 
holic patients,  and  the  above  case  is  a  good  example 
of  this  condition.  His  muscles  were  contracted  from 
the  very  beginning  and  did  not  relax  at  any  stage  of 
the  anaesthesia.  He  was  neither  boisterous  nor  noisy, 
and  made  no  physical  demonstration  whatever. 


230  General  Ancrsthetics  in  Dentistry. 

About  a  month  ago,  two  physicians  brought  to  my 
office  a  third  physician  to  be  anaesthetized.  This  pa- 
tient, a  month  previously,  had  been  brutally  attacked 
by  some  ruffians  and  in  the  fracas  had  the  lower 
maxilla  fractured  on  both  sides  in  the  mental  foramen 
region.  Union  was  just  nicely  established  and  the 
bandages  and  splints  removed  and  it  was  found  that 
the  second  molar  on  the  right  side  had  moved  forward 
in  such  a  way  as  to  prevent  the  mouth  closing  and  we 
all  agreed  that  the  tooth  should  be  extracted.  This 
patient  had  been  under  the  influence  of  liquor  and 
morphine  for  a  month.  He  told  me  afterwards  that  he 
took  three  big  drinks  just  before  coming  to  the  office. 
When  I  commenced  to  ancesthetize  him  one  of  the  phy- 
sicians without  being  told  closed  in  on  his  knees  and 
braced  himself  in  front  of  the  patient.  The  other  phy- 
sician stood  on  the  left  side  and  grasped  the  wrist  of 
each  hand.  I  had  never  had  a  patient  held  like  this 
before,  but  there  was  no  time  to  argue  the  case,  so  I 
said  nothing.  The  tooth  extracted,  the  patient  was  a 
little  excited  and  warned  them  not  to  attempt  that 
again  as  he  had  his  gun  with  him  this  time  and  would 
blow  their  brains  out  if  they  did.  In  about  a  minute 
he  was  all  over  his  anaesthetic.  He  told  me  that  in 
his  dream  the  same  crowd  was  after  him.  I  do  not 
know,  of  course,  what  kind  of  a  time  we  might  have 
had  with  this  man  alone.  The  physicians  told  me 
afterwards  that  they  knew  that  he  was  armed  and  that 
was  why  they  came  over  with  him.  I  was  very  glad 
that  they  came,  because  I  went  through  a  nitrous  oxid 
experience  on  a  former  occasion  when  an  alcoholic  had 


General  Anccsthetics  in  Dentistry.  231 

a  revolver  and  it  took  a  policeman  and  four  men  to  take 
it  from  him. 

After  that  experience,  as  long  as  I  remained  in 
the  South,  I  always,  for  a  man,  felt  his  hip  pocket  be- 
fore administering  gas.  Nearly  every  Southern  man 
in  those  days  carried  a  revolver. 


232  General  Ancesthetics  in  Dentistry. 


LECTURE  XIX. 
Somnoform  Analgesia. 

In  what  class  of  cases  do  I  advocate  somnoform 
analgesia  ?  In  all  painful  conditions  the  dentist  is  called 
upon  to  treat  in  which  the  dread  of  the  operation  or 
the  pain  to  be  inflicted  is  of  such  a  nature  or  char- 
acter as  to  interfere  with  or  mitigate  against  the  per- 
formance on  the  part  of  the  dental  surgeon  of  the  very 
best  operation  for  the  case  under  consideration,  with 
the  exception,  possibly,  of  two  classes  of  cases,  viz.: 
the  removal  of  one  or  more  teeth  that  give  evidence 
that  great  suffering  would  result,  and  the  removal  of 
live  teeth  pulps. 

Somnoform  can  be  used  to  good  advantage  in  all 
painful  conditions  which  the  dentist  is  called  upon  to 
treat. 

There  are  times  in  the  preparation  of  a  sensitive 
tooth  for  filling  when  a  little  more  cutting  must  be 
done,  yet  the  patient  has  reached  the  limit  of  endu- 
rance. Can  you  recall  such  a  case?  A  few  inhalations 
of  somnoform  will  not  only  permit  of  painless  cutting, 
but  the  patient  will  be  rested  and  refreshed  for  the 
remainder  of  the  operation. 

Sometimes  in  preparing  a  tooth  for  a  crown,  just 
at  the  juncture  of  the   enamel   and   dentine,  the   sen- 


General  Anccsthetics  in  Dentistry.  233 

sibility  is  so  great  that  further  cutting  seems  impos- 
sible, yet  more  space  must  be  gained.  Three  or  four 
inhalations  of  somnoform  render  the  patient  insensible 
to  pain. 

A  patient  presents  with  a  case  of  acute  dental  peri- 
cementitis arising  from  a  dead  pulp.  The  tooth  is  so 
sore  that  the  pressure  of  the  tongue  against  it  causes 
excruciating  pain.  The  pulp  chamber  should  be  en- 
tered for  drainage.  In  years  gone  by  I  have  spent  an 
hour  or  more  in  entering  the  pulp  chamber  of  such  a 
tooth.  By  the  use  of  a  few  inhalations  of  somno- 
form, vent  or  drainage  can  be  secured  in  a  minute, 
painlessly. 

A  child  has  been  awake  all  night  crying  because 
of  a  case  of  acute  pulpitis.  She  comes  to  the  office 
next  morning  all  worn  out  from  loss  of  sleep  and 
hours  of  suffering,  added  to  which  is  the  dread  of  being 
hurt.  Softened  dentine  must  be  removed  and  the  pulp 
exposed,  and  the  dental  surgeon  dreads  doing  this 
almost  as  much  as  the  patient  dreads  having  it  done. 
Just  a  little  somnoform  inhaled  will  enable  the  dentist 
to  make  an  exposure  and  seal  in  an  emolient  treatment 
before  the  little  one  opens  her  eyes  or  knows  that  the 
tooth  has  been  touched. 

Exposing  pulps  for  arsenical  application  or  remov- 
ing a  pulp  after  an  arsenical  application  has  remained 
the  requisite  time,  for  those  patients  who  suffer  men- 
tally from  anticipation  of  being  hurt;  evacuating  pus 
in  acute  alveolar  abscess,  lancing  or  removing  a  por- 
tion of  the  gingival  tissue  in  unerupted,  impacted,  or 
belated  third  molars;  removing  deep  cerumal  deposits 


234  General  Anccsthetics  in  Dentistry.  , 

from  the  roots  of  the  teeth  and  cauterizing  deep  pus 
pockets;  opening  into  the  antrum;  amputating  roots 
of  teeth  in  cases  of  chronic  alveolar  abscess ;  operating 
for  dentigerous  cyst,  alveolar  and  maxillary  necrosis; 
simple  extractions  of  teeth,  and  other  operations  that 
dental  surgeons  are  called  upon  to  perform.  Be  hu- 
mane, look  to  the  best  interests  of  your  patients  and 
yourself,  and  with  somnoform  or  some  other  anaes- 
thetic, do  all  these  operations  painlessly.  The  time 
is  coming  when  dental  surgeons  will  look  back 
on  the  present  cruel  and  barbarous  methods  of  oper- 
ating with  pity  and  sorrow  in  their  hearts  just  as 
the  general  surgeon  recalls  the  thousands  of  failures 
he  made  in  the  years  that  have  passed  when  anaes- 
thetics were  not  available.  The  average  lifetime  of 
fillings,  inlays,  crowns  and  bridges  will  be  doubled 
and  trebled  when  we  are  able  to  make  the  kind  of 
preparation  we  well  know  should  be  made,  but  neg- 
lect to  make,  fall  short  of  the  ideal,  because  of  the 
objections  urged  upon  the  part  of  the  patient,  because 
of  the  pain  inflicted. 

In  May,  1908,  I  gave  several  talks  and  clinics 
before  the  Nebraska  State  Dental  Society  at  Omaha. 
As  I  passed  out  of  the  lecture  room  to  the  clinic  room, 
Dr.  Frank  Hetrick  of  Ottawa,  Kan.,  called  to  me, 
"Come  on,  DeFord,  I  have  been  waiting  for  you.  Get 
your  somnoform." 

l^r.  Hetrick's  clinic  was  to  make  two  Ascher  Artifi- 
cial Enamel  fillings  in  the  approximal  surfaces  of  two 
upper  central  incisors.  Tic  remarked,  "I  have  gone 
just  as  far  as  I  can  with  this  case.     The  teeth  have 


General  /liucstlietics  in  Dentistry.  235 

become  so  sensitive  that  I  can  not  even  touch  them 
with  an  excavator."  I  said  to  the  patient,  "Are  you 
v^ilHng  to  take  a  few  whififs  of  somnoform?"  He 
assured  me  that  he  certainly  was,  but  that  he  knew 
it  would  not  be  successful  in  his  case.  Then  he  told 
me  this:  "1  am  a  dentist  and  1  reside  in  Lincoln.  No 
one  has  ever  yet  been  able  to  make  a  correct  cavity 
preparation  in  any  of  my  teeth.  Last  year  at  our  State 
Meeting-,  held  at  Lincoln,  I  sat  four  hours  with  rubber 
dam  adjusted.  Cocaine,  eucaine,  pressure  anaesthesia 
all  availed  nothing.  Worn  out  completely  with  the 
suffering  incident  to  the  operation,  I  could  endure 
no  more,  and  cement  was  placed  in  this  partly  pre- 
pared cavity,  as  had  been  done  on  former  occasions 
with  other  teeth."  "But,"  I  said  to  him,  "y°u  don't 
mind  trying  the  somnoform,  do  you?"  He  replied, 
"I  would  try  anything."  I  explained  that  if  he  experi- 
enced any  further  pain  in  this  operation  that  he  had 
only  himself  to  blame.  That  the  moment  he  felt  the 
slightest  pain  or  thought  that  he  was  going  to  be  hurt 
to  simply  raise  his  hand  so  we  could  see  it,  and  that 
Dr.  Hetrick  would  cease  immediately.  I  administered 
about  three  inhalations  of  somnoform  and  signalled 
to  Dr.  Hetrick  to  proceed.  The  Doctor  had  almost 
completed  the  preparation  he  wished  in  one  tooth  when 
the  patient's  hand  started  to  ascend.  Some  one  in  the 
audience  called  out,  "Is  he  hurting  you"?  The  patient 
replied,  "Not  a  bit  and  I  do  not  want  to  be  hurt."  I 
administered  about  three  more  inhalations  of  somno- 
form, and  this  time  both  cavity  preparations  were  com- 
pleted without  the  least  pain.     This  gentleman  was 


236  General  Anesthetics  in  Dentistry. 

at  no  time  unconscious.  He  looked  up  to  me  and  said, 
"Doctor,  I  would  go  to  Europe,  if  necessary,  before  I 
would  ever  have  another  cavity  prepared  in  any  other 
way."  The  entire  time  from  the  first  inhalation  till 
the  conversation  just  related  took  place  was  less  than 
three  minutes,  some  one  in  the  audience  announced. 

About  a  month  since  one  of  our  students,  as  the 
result  of  a  dead  pulp  in  an  upper  later  incisor,  pre- 
sented with  a  case  of  acute  septic  apical  pericementitis. 
The  slightest  touch  of  lip,  tongue  or  food  caused 
excruciating  pain.  Three  inhalations  of  somnoform 
proved  ample  to  induce  a  state  of  analgesia  sufficient 
to  enter  the  pulp  chamber  with  a  bur  through  the  lin- 
gual pit.  This  young  man  was  very  timid,  inhaled 
the  somnoform  with  misgivings  as  to  the  result,  but 
after  the  very  first  inhalation  the  stimulating  effect 
was  produced,  fear  was  dispelled,  and  he  shook  with 
laughter  during  the  drilling,  and  did  not  experience  the 
slightest  pain.  The  entire  procedure  required  less 
than  a  minute.  At  this  juncture  a  dentist  entered  the 
room  and  we  explained  what  we  had  been  doing.  He 
expressed  regret  at  not  having  been  able  to  witness  the 
operation.  I  had  him  examine  the  case  and  test  the 
condition  present  by  gently  percussing  the  tooth. 
Then  I  said  to  the  young  gentleman :  "Will  you  take 
the  same  amount  of  somnoform  again?"  He  con- 
sented. In  fifteen  seconds,  with  three  inhalations,  he 
was  in  this  same  condition  of  joyous  analgesia,  and  tap- 
ping the  tooth  so  that  the  sound  could  be  heard 
throughout  the  entire  room  elicited  no  evidence  on  his 
part  that  he  experienced  the  slightest  discomfort. 


General  Anesthetics  in  Dentistry.  23'? 

Soon  after  opening  our  clinic  at  the  beginning  of 
the  present  school  year,  a  young  man  presented  for 
a  large  amount  of  dental  work,  a  student  at  the  Agri- 
cultural College  some  forty  miles  distant.  This  case 
would  have  taxed  the  ingenuity  and  skill  of  the  most 
successful  of  dental  practitioners.  Among  other  cari- 
ous cavities  there  were  five  along  the  gingival  margins 
of  the  lower  anterior  teeth. 

These  were  all  so  deep  as  to  demand  pulp  removal. 
They  were  so  sensitive  as  to  render  instrumentation 
impossible.  They  were  so  deep  or  extended  down  so 
far  gingivally  that  rubber  dam  adjustment  was  not  to 
be  considered.  Saliva  was  so  excessive  the  cavities 
could  not  be  kept  dry  a  sufficient  length  of  time  by 
means  of  cotton  rolls  and  napkins.  Patient  could  come 
only  on  Saturdays. 

This  is  one  of  the  cases  in  which  I  would  prefer 
a  condition  of  anaesthesia  for  operation  rather  than 
analgesia.  A  few  inhalations  of  somnoform  were  ad- 
ministered ;  in  about  forty-five  seconds  the  patient  was 
anaesthetized.  With  rapidly  rotated,  good-sized  bur, 
the  five  pulp  chambers  were  thoroughly  opened,  the 
patient  showed  not  the  slightest  evidence  of  pain  and 
denied  feeling  any  upon  awaking,  and  the  entire  time 
consumed  was  less,  I  should  say,  than  two  minutes 
from  the  first  inhalation  of  somnoform.  Each  pulp 
being  completely  exposed,  no  more  drilling  was  nec- 
essary, and  the  operation  was  completed  by  the  use 
of  pressure  anaesthesia  by  the  student  in  charge  of  the 
case. 

Jlundreds  of  similar  Q^ses  could  be  cited,     They 


238  General  Anccsthetics  in  Dentistry. 

are  of  every  day  occurrence.  Indeed,  several  times 
every  day  such  cases  present  in  the  practice  of  every 
dental  surgeon,  yet  how  few  men  avail  themselves 
of  such  an  easy  method  of  handling  these  cases. 

In  giving  a  detailed  description  of  how  to  proceed 
in  these  cases  it  will  be  necessary,  of  course,  to  repeat 
in  substance,  if  not  in  language,  some  things  that 
have  already  been  said  in  explaining  the  technic  of 
analgesia  when  nitrous  oxid  and  oxygen  was  the  agent 
under  consideration. 

The  De  Ford  Somnoform  Inhaler. 

The  De  Ford  Somnoform  Inhaler  has  been  con- 
structed to  meet  this  class  of  cases.  By  means  of  this 
inhaler,  continuous  analgesia  can  be  maintained  with- 
out removing  the  inhaler  from  the  face  as  must  be 
done  with  all  other  somnoform  inhalers. 

In  order  to  simplify  matters  let  us  assume  that  an 
occlusal  cavity  in  a  lower  first  molar  has  become  so 
sensitive  that  the  patient  seems  physically  unable  to 
have  the  operation  completed,  yet  the  cavity  is  not 
properly  shaped  for  the  gold  inlay  you  have  contracted 
to  make. 

Adjust  the  appliance  to  the  nose,  making  it  tight 
by  means  of  the  retaining  strap.  Prop  the  mouth  open 
as  wide  as  patient  will  tolerate.  Then  adjust  the  mouth 
cover,  and  when  it  assumes  the  proper  position,  tighten 
the  set  screw.  See  that  the  exhalation  valve  is  closed 
in  the  nasal  inhaler.  Sec  that  the  valve  is  closed  that 
holds  back  the  somnoform  and  prevents  it  from  escap- 
ing till  it  is  needed,    With  the  valve  in  this  position, 


General  Anccsthetics  in  Dentistry.  239 

the  patient  inhales  air  only  and  no  somnoform.  Steady 
the  mouth  cover  with  the  hand  and  turn  on  just  a 
trace  of  somnoform,  then  a  little  more.  Let  the  patient 
breathe  normally.  Say  nothing  about  the  respira- 
tion. Do  not  attempt  to  tell  the  patient  how  to  breathe 
unless  the  breathing  does  not  suit  you.  If  the  patient 
breathes  too  deeply,  say  in  a  quiet,  firm  voice,  "It  is 
not  necessary  to  breathe  so  deeply."  If  breathing  is 
too  shallow,  "Breathe  a  little  deeper,  please."  If  you 
do  not  get  patients  confused  by  trying  to  tell  them  how 
to  breathe  in  the  beginning,  you  will  seldom  have  to 
say  anything  about  breathing. 

Have  the  patient  understand  that  if  pain  is  being 
felt,  the  lifted  hand  will  indicate  the  same,  and  admin- 
ister a  little  more  anaesthetic.  After  two  or  three  in- 
halations say  to  the  patient,  "Do  you  feel  drowsy;  are 
you  getting  sleepy?"  The  nature  of  the  reply  will 
indicate  to  you  their  condition.  If  they  answer  up 
quickly,  and  you  discover  the  natural  tone  of  voice,  it 
is  too  soon  to  begin  to  operate.  If  they  drawl  out 
"y-e-s,  yes,"  in  a  sleepy,  uninteresting  manner,  you 
can  usually  begin  to  operate. 

Elevate  the  mouth  cover ;  shut  of  the  somnoform. 
Admit  a  little  more  somnoform  when  it  seems  neces- 
sary. Just  as  consciousness  is  being  lost  begin  to 
operate,  gently  testing  the  sensitivity  of  the  tooth. 

It  will  not  do  at  this  stage  to  hold  the  bur  hard 
against  the  dentine  and  run  the  engine  at  highest 
speed.  If  easy  cutting  can  be  accomplished  without  a 
protest  on  the  part  of  the  patient,  keep  on  cutting, 
saying  all  the  time,  "'Am  I  hurting  you?"     "Do  you 


240  General  Anesthetics  in  Dentistry. 

feel  pain?"  etc.  If  the  hand  is  raised  or  the  facial 
expression  indicates  that  pain  is  being  felt,  a  little 
more  somnoform  is  indicated.  When  patients  refuse 
to  answer  they  are  usually  deeper  than  necessary.  In 
the  state  just  between  sleeping  and  waking  you  can 
usually  cut  the  most  sensitive  dentine  without  the 
slightest  pain. 

You  have  only  by  experience  to  learn  to  maintain 
this  analgesic  stage. 

If  you  are  a  tyro  in  anaesthetics,  have  had  no 
practical  experience,  read  carefully  several  times  the 
lecture  on  "Elements  of  Success"  before  attempting 
to  administer  somnoform  for  other  operations  than 
extracting. 

Indeed,  in  order  to  succeed  in  this  line  of  practice, 
one  should  administer  somnoform  for  extraction  cases 
till  he  is  familiar  with  the  physiological  action  of  this 
anaesthetic,  till  he  has  gained  confidence  in  himself  and 
is  master  of  the  situation. 

This  technic  is  applicable  to  every  case  in  which 
the  rubber  dam  is  not  adjusted. 

In  all  cases  in  which  the  rubber  dam  is  in  position, 
the  mouth  cover  is  unnecessary.  The  mouth  cover 
is  easily  removed  by  sliding  it  to  the  left.  The  rub- 
ber dam  now  excludes  the  air  from  the  mouth  and  we 
proceed  exactly  as  before.  As  no  somnoform  escapes 
from  the  mouth  it  is  not  necessary  to  admit  quite  as 
much  to  the  nasal  inhaler.  The  amount  varies  with 
individual  cases. 

In  the  case  of  lady  patients,  when  you  make  your 
appointment  for  a  given  operation,  if  you  anticipate  VIS" 


General  Aitccst/wtics  in  Dentistry.  241 

ing  somnoform  or  think  perhaps  it  may  be  ncccssary 
in  this  case  to  do  properly  what  you  wish,  request  them 
to  leave  off  the  corset  when  dressing  for  the  office,  as 
this  saves  complications  after  the  patient  arrives.  You 
always  get  a  more  comfortable,  a  safer  and  a  more 
successful  anaesthesia  with  the  corset  off,  and  do  not 
run  the  same  risk  of  nausea.  It  is  better  "also,  -.vhen 
convenient,  to  make  appointments  two  or  three  hours 
after  a  meal,  or  have  the  patient  eat  lightly  or  not  at 
all  if  the  appointment  comes  just  after  the  breakfast 
or  lunch  hour. 

If  a  patient  presents  with  a  severe  case  of  acute  al- 
veolar abscess,  the  result  of  a  dead  pulp,  with  a  tooth 
so  sore  that  it  seems  out  of  the  question  to  undergo  the 
pain  of  entering  the  pulp  chamber,  insert  mouth-prop 
and  without  adjusting  the  dam.  anaesthetize  the  patient 
just  as  you  would  for  the  extraction  of  teeth.  With 
a  good  engine  and  a  sharp  bur  enter  pulp  chamber. 

If  the  operation  is  the  removal  of  a  live  pulp,  with 
the  dam  adjusted  and  a  prop  inserted  administer  som- 
noform as  you  would  for  an  extraction  case. 

If  you  wish  to  thoroughly  cauterize  pus  pockets  or 
curette  them,  have  all  instruments  and  the  medicinal 
agent  to  be  used  in  readiness,  adjust  the  mouth-prop 
and  induce  somnoform  analgesia. 

Take  time  to  bathe  the  tissues  with  a  cocaine  solu- 
tion or  cocaine  ointment  to  prevent  or  lessen  after- 
pain.  In  any  case  in  which  the  analgesia  state  is  not 
sufficient  for  comfortable  operating,  only  two  or  three 
more  inhalations  are  necessary  to  induce  surgical 
anaesthesia. 


242  General  Anccsthetics  in  Dentistry. 

One  such  thorough  treatment  under  an  anaesthetic 
does  more  good,  frequently,  than  weeks  of  treatment 
with   milder   agents. 

In  preparing  sensitive  teeth  for  crowns  or  abut- 
ments, the  amount  of  cutting  necessary  will  suggest  the 
method  to  be  employed.  With  some  patients  the  grind- 
ing is  far  more  objectionable  and  more  wearing  and 
exhausting  than  severe  pain  for  the  same  length  of 
time.  If  the  grinding  is  to  cover  several  minutes,  I 
would  adopt  the  same  method  as  described  for  cavity 
preparation,  without  adjusting  the  rubber  dam.  If 
just  a  little  cutting  was  necessary,  when  the  sensitive- 
ness became  too  severe  I  would  suggest  a  deeper  anaes- 
thesia and  complete  the  grinding  without  prolonging 
the  anaesthesia. 

It  is  not  necessary  for  me  to  dwell  upon  the  advan- 
tages of  operating  under  anaesthesia.  It  is  apparent  to 
every  one,  and  a  safe  method  by  which  this  could  be 
accomplished  has  long  been  looked  for  and  prayed  for, 
not  only  by  the  dental  surgeon,  but  by  the  patient. 
Only  an  infinitesimal  number  remain  away  from  the 
dentist  on  account  of  the  fee.  The  masses  postpone 
dental  operations  and  allow  their  teeth  to  fall  to  pieces 
in  their  mouths  because  of  the  torture  that  must  be 
endured  in  having  them  operated  upon.  Could  some 
man  invent  a  scheme  by  which  he  could  restore  all 
diseased  teeth  to  health  and  the  patient  had  but  to 
have  him  glance  into  his  mouth,  when  instantaneously, 
inlays,  fillings,  crowns  and  bridges  would  fly  into  posi- 
tion, the  check  book  would  be  produced  and  any  price 
named  would  be  cheerfully  paid. 


General  .InccstUet'ics  in  Dentistry.  243 


LECTURE  XX. 

Chloroform  Analgesia. 

Dr.  Austin  C.  Hevvett,  of  Chicago,  was  the  first  man 
to  advocate  the  performance  of  surgical  operations  in 
a  state  of  chloroform  analgesia.  He  was  one  of  the  first 
men,  if  not  the  first,  in  the  United  States  to  use  chloro- 
form. As  soon  as  the  news  reached  America  that  Sir 
James  Y.  Simpson  had  used  chloroform  successfully, 
Dr.  Hewett  imported  a  small  quantity  from  London  at 
a  fabulous  price  and  commenced  to  experiment.  At  the 
time  the  chloroform  arrived,  Dr.  Hewett  was  suffering 
with  an  abscessed  lower  molar.  He  took  a  few  inhala- 
tions of  chloroform  and  proceeded  to  evacuate  the  pus. 
He  pressed  a  lance  into  his  gum  without  any  sensation 
whatever.  L'pon  removing  the  lance  he  was  amazed, 
for  the  stain  on  the  blade  indicated  that  it  had  passed 
a  quarter  of  an  inch  into  the  tissue.  He  then  took  a 
forceps,  and,  adjusting  it  to  his  tooth,  made  careful 
lateral  movements  without  pain.  Thus  encouraged, 
he  extracted  his  own  tooth  without  the  least  discom- 
fort. Dr.  Hewett  was  at  this  time  a  medical  student 
and  for  years  after  graduating  had  a  large  medical  and 
surgical  practice  in  Southeastern  Michigan.  For  a 
period  of  more  than  twenty  years  he  performed  all 
kinds  of  surgical  operations  in  a  stage  of  analgesia, 


244  General  Ancesthetics  in  Dentistry. 

notwithstanding  all  the  authorities  in  this  country  and 
abroad  maintained  that  this  was  a  most  dangerous  pro- 
cedure. During  all  these  years,  had  a  death  occurred 
while  operating  in  this  stage  of  analgesia,  he  probably 
could  not  have  found  a  medical  man  in  all  the  world  to 
go  on  the  witness  stand  and  testify  in  his  favor.  After 
an  extensive  medical  and  surgical  practice  covering  a 
period  of  twenty-five  years,  realizing  the  great  neces- 
sity for  the  use  of  anaesthetics  in  dentistry,  he  aban- 
doned medicine  and  opened  a  dental  office  in  the  City 
of  Chicago,  quickly  establishing  a  large  and  lucrative 
practice  by  the  use  of  chloroform  for  all  operations 
upon  the  teeth.  Indeed,  he  refused  to  operate  in  pain- 
ful conditions  unless  the  patient  inhaled  chloroform. 

In  May,  1893,  and  again  in  May,  1895,  Dr.  Hewett 
read  papers  before  the  Iowa  State  Dental  Society  on 
chloroform  analgesia,  which  so  impressed  the  society 
that  a  committee  was  appointed  to  visit  Dr.  Hewett 
at  his  office  in  Chicago  and  make  a  report  of  what  he 
was  doing.  As  the  writer  was  the  chairman  of  that 
committee  and  wrote  the  report  which  was  printed  in 
the  proceedings  of  the  Iowa  State  Dental  Society,  for 
May,  1896,  he  takes  the  liberty  of  reproducing  portions 
of  that  report  in  these  lectures. 

"We,  the  undersigned,  a  committee  appointed  at  the 
last  annual  meeting  of  the  Iowa  State  Dental  Society 
to  visit  Chicago  and  investigate  the  Hewett  method  of 
anaesthesia,  beg  leave  to  submit  the  following  report: 
On  the  morning  of  July  17th,  1895,  at  9  A.  M.,  per 
agreement,  the  committee  met  at  the  Palmer  House 
and  proceeded  to  the  office  of  Dr.  A.  C.  Hewett,  No. 


General  Ancesthetics  in  Dentistry.  245 

491  West  Adams  Street.  We  found  Dr.  Hewett,  his 
assistants  and  a  number  of  patients  awaiting  our  ar- 
rival. The  committee  had  placed  in  Dr.  Hewett's 
hands  a  month  or  more  in  advance  a  list  of  operations 
they  wished  to  have  him  perform,  covering  the  entire 
field  of  operative  dentistry.  When  we  arrived,  Dr. 
Hewett  extended  to  the  members  of  the  committee  the 
privilege  of  bringing  to  his  office  any  one  they  wished, 
designating  the  operation  to  be  performed.  Further, 
the  members  of  the  committee  were  not  only  invited, 
but  urged  to  perform  the  operations  themselves,  he 
administering  the  chloroform  and  designating  when 
to  operate. 

"Case  I.  Operation — Preparation  of  Cavity  of  Decay. 
"Bessie  W — ,  age  eleven  ;  frail,  delicate  child,  poorly 
nourished ;  anaemic.  Cavity  of  decay  in  lower  left  first 
molar  grinding  surface.  Engine  was  used  till  the  tooth 
became  very  sensitive,  then  chloroform  was  adminis- 
tered— twenty  inhalations.  Time  of  preparation  of 
cavity,  two  minutes.  Child  reported  'no  pain'  after 
inhaling  the  chloroform.  Said  she  'would  not  dread 
to  come  again.'    Amalgam  was  used  for  the  filling. 

"Case  II.     Operation — Extraction  of  Roots  of  Tooth. 

"Miss  McI — ,  age  about  thirty  ;  roots  of  lower  right 
first  molar  beneath  the  gum.  Used  modeling  com- 
pound for  an  impression ;  impression  enlarged  a  little. 
In  this  was  placed,  along  the  sides,  cotton,  saturated 
with  'Hewett's  compound  cocaine  pigment.'  The  ])arts 
were  thoroughly  dried,  the  four' per  cent,  cocaine  solu- 
tion applied  to  remove  mucus  and  foreign  substances; 


246  General  Anccsthctics  in  Dentistry. 

the  modeling  compound  slipped  back  in  position  and 
the  patient  instructed  to  bring  the  teeth  together. 
Now  the  patient  was  ready  for  the  chloroform  and  took 
sixteen  inhalations ;  roots  were  removed.  On  being 
questioned,  patient  said,  'No  hurt,  nothing,  not  the 
slightest  pain,  but  knew  when  I  opened  my  mouth  and 
when  the  instrument  was  applied.'  No  unpleasant 
symptoms. 

"Case  III.     Operation — Amputation  of  Pulp. 

"Miss  McI — ,  age  about  twenty-seven ;  dried  gums 
and  used  compound  cocaine  pigment  prior  to  adjusting 
the  rubber  dam. 

"Tooth,  upper  right  bicuspid ;  surface  involved, 
mesial.  Broke  down  the  enamel  walls  with  a  chisel  be- 
fore administering  chloroform.  Patient  never  had 
taken  chloroform  before.  Eighteen  inhalations.  She 
seemed  to  be  suffering,  judging  from  the  facial  ex- 
pression. The  coronal  portion  of  the  pulp  was  entirely 
removed  by  a  fast-rotating  bur.  Pulp  bled  profusely ; 
dressed  with  eucalyptol.  After  the  hemorrhage  ceased, 
a  pellet  of  tin  foil  was  burnished  over  the  remaining 
portions  of  the  pulp  and  cavity  filled  with  cement. 
Operation  to  be  completed  at  another  sitting.  Patient 
reported  'no  pain,'  but  knew  what  was  going  on. 
When  asked  if  she  had  been  instructed  not  to  eat  be- 
fore coming,  replied  that  nothing  had  been  said  to  her 
about  that ;  she  had  eaten  breakfast  as  usual  and  a 
hearty  lunch.  On  being  further  questioned,  said  'I 
would  not  dread  to  have  the  same  operation  performed 
on  another  tooth.' 


General  Aiiccstlietics  in  Dentistry.  247 

"Case  IV.     Operation — Extraction  of  Roots  of  Tooth. 

"j\liss  ,  age  thirty-five;  roots  of  lower  right 

second  molar  beneath  the  gum.  Took  impression  with 
modeling  compound;  dried  the  parts;  removed  mucus 
with  four  per  cent,  cocaine  solution,  then  replaced  the 
impression  containing  cotton  saturated  with  compound 
cocaine  pigment,  allowing  to  remain  about  a  minute 
before  and  during  inhalation  of  chloroform;  thirty-two 
inhalations.  This  was  a  difficult  case,  the  tissues  sur- 
rounding being  highly  inflamed  and  sensitive.  Patient 
reported  no  pain.  Said  she  had  been  trying  for  two 
years  to  get  the  courage  to  have  the  roots  removed. 
Never  took  chloroform  before ;  no  nausea,  no  unpleas- 
ant after  symptoms,  although  she  had  eaten  a  hearty 
lunch  just  before   leaving  home. 

"Case  V.     Operation — Shaping  Tooth  for  Gold  Crown. 

"Mrs.  W — ,  age  forty-five;  lower  right  second  molar; 
patient  a  delicate,  frail  woman.  Applied  four  per  cent, 
cocaine  solution  to  the  gum ;  ground  tooth  with  corun- 
dum-wheels till  it  became  sensitive  at  all  points ;  in- 
deed, very  painful.  Chloroform  was  now  administered, 
six  inhalations,  and  grijiding  continued  until  patient  in- 
dicated it  was  painful,  then  eight  more  inhalations  of 
chloroform,  and  the  operation  was  completed.  Tooth 
was  cauterized  with  weak  solution  of  silver  nitrate, 
and  patient  dismissed.  Time,  about  five  minutes;  tooth 
having  small  neck  and  large  crown,  bell-shaped,  con- 
siderable cutting  was  necessary. 


248  General  Anccsthetics  in  Dentistry. 

"Case  VII.     Operation — Amputation  of  Pulp. 

"Mr.  M — ,  age  thirty-seven.  Upper  left  cuspid, 
mesial  surface.  Four  per  cent,  solution  of  cocaine 
applied  to  the  gum,  rubber  dam  adjusted  and  chloro- 
form administered.  Pulp  chamber  entered  with  rapid- 
ly  rotated  bur.  Pulp  bled  profusely,  eucalyptol  used 
as  a  dressing;  tin  foil  burnished  over  the  remaining 
pulp,  and  cavity  filled  with  cement.  Patient  felt  some 
pain ;  no  nausea,  headache  or  uncomfortable  symp- 
toms from  the  chloroform. 

"Case  VIII.   Operation — Extraction  and  Replantation. 

"Miss ,  age  twenty-five.     Superior  right  central 

incisor  elongated  a  quarter  of  an  inch  beyond  the 
cutting  edge  on  the  adjoining  tooth.  Impression  taken 
and  cocaine  applied  as  in  former  extractions,  and  held 
in  place  while  taking  twenty-six  inhalations  of  chloro- 
form. Pulse,  before  taking  the  anaesthetic,  120  per 
minute,  at  time  of  extraction,  100.  Tooth  extracted 
and  bathed  in  eucalyptol,  apical  foramen  enlarged  and 
pulp  removed ;  pulp  chamber  and  canals  filled  with 
chloro-percha.  Socket  deepened  with  bur,  tooth 
placed  in  position  and  driven  up  with  a  hammer,  bring- 
ing the  cutting  edge  on  a  line,  with  the  left  central. 
A  splint  was  constructed  and  applied  and  the  patient 
dismissed  till  the  following  day.  Time  consumed 
from  beginning  to  close  of  the  operation,  twelve  min- 
ues;    no   pain. 

"Case  IX.     Operation — Preparing  Tooth  for  Filling. 

"Prof.  C — ,  age  thirty-six.     Upper  right  first  molar, 


General  .liucsthetics  in  Dentistry.  "^49 

mesial  and  occlusal  surfaces.  Applied  compound  co- 
caine pigment  to  the  gum  and  adjusted  rubber  dam; 
used  engine  till  cutting  was  very  painful ;  then  ad- 
ministered chloroform,  twelve  inhalations.  The  Pro- 
fessor expressed  himself  pleased  with  the  results,  as 
the  cavity  was  ready  for  filling  in  about  three  min- 
utes." 

"Dr.   Hewett's   Attitude   in   Relation  to   Chloroform. 

"  'To  more  fully  define  my  attitude  in  relation  to 
chloroform  as  an  obtundent,'  says  Dr.  Hewett,  'I  wish 
to  say  that  in  all  the  range  of  operative  dentistry,  and 
in  the  demands  of  oral  surgery,  there  are  but  four  to 
six  operations  demanding  or  justifying  its  exhibtion 
to  complete  anaesthesia.  The  obtundent  influence  is 
ample.  Under  no  circumstance  is  a  dentist  justified 
in  fully  anaesthetizing  a  patient  for  extraction  of  teeth 
or  for  minor  operations  or  oral  surgery.  During  a 
somewhat  lengthened  practice  never  an  accident  or 
an   approach   to  an  accident  has  occurred.' 

"As  a  result  of  careful  study  and  extensive  use,  Dr. 
Hewett  does  not  hesitate  to  commend  its  general  use 
as  an  obtundent.  (Please  observe  the  emphasis  on 
that  word.)  When  given  as  Dr.  Hewett  describes,  'it 
is  safe  for  the  young  and  aged,  the  robust  and  feeble, 
the  sick  and  the  healthy,  the  nervous  and  the  stolid. 
Thus  used  as  an  alleviator  of  pain,  chloroform  has  no 
known  rival.  A  substance  in  the  hands  of  the  un- 
skilled and  reckless,  as  dangerous  to  human  life  as 
prusic  acid  or  dynamite,  but  used  properly,  legiti- 
mately, as  safe  as  the  odor  from  the  heart  of  a  rose.' 
(Hewett.) 


250  General  Anccsthctics  in  Dentistry. 

"How  Administered. — 'Having  tested  numberless 
devices,  from  a  sponge  to  an  elaborate  machine,  I 
(Dr.  Hewett)  have  chosen  a  means  so  simple  as  to 
be  almost  ridiculous.  A  wide-mouthed,  half-ounce 
to  ounce  bottle,  an  ordinary  morphine  bottle,  is  as 
good  as  any.  Any  glass  bottle  two  and  one-half  inches 
high,  an  inch  and  one-half  in  diameter,  with  mouth 
three-quarters  of  an  inch  across,  will  do.  Of  course,  it 
should  be  clean.  If  the  chloroform  is  to  be  kept  in 
the  bottle  after  administration,  the  cork  or  stopper 
should  seal  hermetically,  and  the  bottle  wrapped  in 
dark  paper  and  kept  in  a  dark  place.  The  chloroform 
should  be  pure,  never  of  a  doubtful  manufacture.  No 
preparation  of  the  patient  is  necessary,  except  that  an 
empty  stomach  is  to  be  preferred.  Or  if  the  drug  is 
to  be  given  soon  after  a  meal,  the  food  should  be 
light  in  quality  and  quantity;  otherwise,  if  the  obtund- 
ent effect  is  pushed  to  or  near  the  anaesthetic  line, 
slight  nausea  may  supervene — the  only  ill  effect  Dr. 
Hewett  has  observed,  even  with  the  stomach  over- 
loaded. 'Place  not  more  than  two  or  three  drams  of 
chloroform  in  the  bottle.  With  the  bottle  open,  place 
it  near  one  nostril  of  the  patient  nearly  on  a  level  with 
the  nose,  rememl)cring  that  the  vapor  of  chloroform 
is  heavier  than  the  atmosphere,  and  the  narcotized  air 
tends  to  fall.  Compress  the  opposite  nostril,  and 
direct  the  patient  to  take  long,  steady  inhalations 
across  the  bottle's  mouth.  Do  not  tolerate  spasmodic 
or  jerky  breathing.  When  an  inhalation  has  occurred, 
remove  the  bottle  so  that  nothing  exhaled  shall  enter 
to   contaminate   the    chloroform.     At   first   the    bottle 


General  Anccsthetics  in  Dentistry.  251 

should  be  aistant  enough  for  only  the  faintest  odor 
to  be  detected;  at  no  time  near  enough  to  irritate  the 
fibrillae  of  nerves  spread  out  upon  the  Schneiderian 
membrane,  the  throat  and  lungs.  Do  not  give  the 
peripheral  nerves  a  shock.  Ihe  medulla  oblongata 
lies  closely  contiguous,  and  will  respond  to  the  irri- 
tation all  too  readily.  Remember  that  the  nerves  of 
the  mouth,  nose,  throat  and  lungs  in  their  ultimate 
distribution,  if  on  a  plane,  cover  a  space  of  twelve  to 
fourteen  hundred  feet,  all  readily  accessible  to  the  nar- 
cotic-laden air.  Nerve  impulse  largely  controls  the 
sanguineous  circulation.  The  blood  absorbs  the  drug, 
and  its  globules  roll  over  each  other  to  the  heart,  to 
be  sent  out  lo  the  brain,  viscera  and  ganglia  again. 

"  'Avoid  shock,  the  first  more  common  cause  of 
death  from  chloroform.  Allow  the  chloroform  to  steal 
over  the  peripheral  sentinels  so  gradually,  so  warily, 
that  it  shall  not  fire  an  alarm  to  the  trigemina  and 
medulla.  As  the  long,  regular  breathing  goes  on,  the 
bottle  can  be  placed  nearer  the  nose  till  stronger  vapor 
is  taken.  Presently  the  eyelids  will  begin  to  droop 
or  "wink"  lazily,  the  muscles  somewhat  relax,  and 
an  obtundure — to  coin  a  word — creeps  over  the 
nerves.' 

"In  such  a  state  Dr.  Hewett  extracted  his  own 
tooth,  and  in  such  a  state  operates  for  his  patients. 
In  this  condition  the  drill  or  bur  can  be  carried  to  the 
live  pulp  and  the  pulp  amputated,  and  afterwards  the 
patient  will  say,  'I  knew  what  you  were  doing,  but 
it  did  not  hurt.'  In  the  case  of  children,  they  will 
sometimes   moan  and   cry   out,   but   after   restoration 


252  General  Ancusthetics  in  Dentistry. 

express  no  resentment,  and  all  dread  of  subsequent 
operations  is  dispelled.  From  what  we  saw  and  learned 
in  Dr.  Hewett's  ofifice,  the  committee  makes  the  fol- 
lowing observations : 

"That  Dr.  Austin  C.  Hewett,  in  his  method  of 
administering  chloroform  for  surgical  operations,  is  at 
variance  with  all  known  authorities  in  that 

''First.  His  patients  are  not  placed  in  the  recum- 
bent position. 

"Second.  That  he  operates  in  the  first  stage  when 
an  obtundent  effect  is  produced  rather  than  the  stage 
of  complete  anaesthesia,  and  denies  that  shock  is  ever 
produced,  when  chloroform  is  administered  as  he 
directs,   from  operating  in   the  'obtundure'  stage. 

"Third.  That  in  thirty  years'  experience  in  his 
method  of  administering  chloroform  for  dental  and 
minor  surgical  operations  no  dangerous  symptoms 
have  ever  been  observed. 

"Fourth.  That  pain  can  be  reduced  to  a  minimum, 
or  be  entirely  overcome,  and  operations  on  the  teeth, 
other  than  extracting,  can  be  performed  in  a  third  to  a 
quarter  of  the  time  ordinarily  required. 

"Fifth.  That  an  operator  can  do  from  a  third  to 
half  more  work  at  the  chair  each  day  by  using  chloro- 
form, and  save  fifty  per  cent,  of  nerve  force  that 
ordinarily  is  expended  in  quieting  and  encouraging 
patients. 

"Further,  tliat  wc  were  gratified  at  the  results  pro- 
duced. 

"Daily  we  are  amputating  nerves,  disemboweling 
them,  causing  groans  and  entreaties,  tears,  shock  often 


General  Anaesthetics  in  Dentistry.  253 

to  syncope,  sometimes  collapse."  We  believe  that  it 
is  as  incumbent  on  dentists  to  perform  operations 
painlessly  as  physicians,  and  that  Dr.  A.  C.  Hewett 
has  made  this  possible,  that  the  average  painstaking, 
mtelligent  practitioner,  with  proper  instruction,  can 
icarn  to  use  this  method  advantageously. 

"  'It  was  from  the  discovery  of  Sir  Humphry  Davy 
that  the  inhalations  of  nitrous  oxid  gas  would  relieve 
the  pain  of  cutting  a  wisdom-tooth  that  the  first  notion 
of  inducing  anaesthesia  by  inhaled  vapors  took  its 
rise.  It  was  for  the  extractiort  of  a  tooth  that  Horace 
Wells  gave  to  the  notion  its  first  practical  embodi- 
ment. For  a  similar  operation,  Morton  succeeded  in 
inducing  insensibility  by  means  of  ether.  The  first 
operation  performed  under  the  influence  of  ether  was 
the  extraction  of  a  tooth.'  Who  has  a  better  right 
than   the   dental   surgeon   to   use   anaesthetics? 

"We  believe  that  a  chair  of  anaesthesia  should  be 
established  in  every  dental  school,  in  order  that  anaes- 
thesia, both  local  and  general,  may  be  scientifically 
studied  and  taught.  That  the  resolution  on  the  records 
of  this  society  opposing  the  use  of  chloroform  in  dental 
practice  should  be  declared  null  and  void.  That  the 
dental  profession  at  large,  as  well  as  this  society,  owes 
a  debt  of  gratitude  and  a  vote  of  thanks  to  Dr.  A. 
C.  Hewett  for  making  public  his  discovery.  That 
the  Iowa  State  Dental  Society  is  indebted  to  Dr. 
Hewett  for  papers  and  addresses  on  this  subject  on 
several  occasions,  and  especially  for  the  hearty,  hos- 
pitable  manner  in  which  he  received  the  committee 


25-i  General  Anccsthetics  in  Dentistry. 

which  you  sent  to  Chicago  to  make  the  investigation 
set  forth  in  this  report. 

''Signed,  W.  H.  DeFord, 
"Geo.  W.  Miller, 
"L.  K.  Fullerton." 

I  soon  learned  to  operate  successfully  under  chloro- 
form analgesia,  selecting  at  first  the  more  favorable 
cases  and  later,  after  gaining  confidence,  using  it  when- 
ever desired.  It  is  not  my  purpose  to  burden  you 
with  the  citation  of  many  cases,  but  will  relate  two 
characteristic  of  hundreds  that  might  be  related. 

Mrs.  N —  came  to  me  to  have  removed  the  roots 
of  a  lower  third  molar  that  had  been  left  by  another 
operator.  Three  weeks  previously,  this  tooth  had  been 
fractured  in  an  attempt  to  remove  it,  and  Mrs.  N — 
had  been  confined  to  her  home  ever  since.  An  ap- 
pointment was  made  to  operate  the  next  day  at  the 
office  of  her  physician  promptly  at  twelve  o'clock. 
This  physician  and  his  partner  had  adminstered  anaes- 
thetics for  me  for  several  years  and  they  were  both 
most  excellent  anaesthetists.  The  patient  proved  to  be 
very  antagonistic,  and  it  was  two  hours  before  we  suc- 
ceeded in  anaesthetizing  her  sufficiently  for  the  oper- 
ation and  four  hours  more  before  the  patient  could 
be  removed  to  her  home.  About  six  months  later, 
the  same  patient  presented  complaining  of  the  lower 
third  molar  on  the  right  side.  I  refused  to  operate 
for  this  case  unless  she  would  take  chloroform  my 
way.  (Ilewett  method.)  We  tried  both  ether  and 
chloroform  for  the  previous  operation  and  she  fought 
like  a  tiger  and  tired  us  all  out,  and  I  did  not  care  to 


General  Amcsthctics  in  Dentistry.  255 

repeat  that  experience.  I  explained  the  Hewett  method 
and  made  an  appointment.  She  kept  the  appointment 
promptly,  but  could  not  muster  up  enough  cour- 
age for  the  operation.  Three  times  she  backed  out 
after  coming  to  the  office.  The  fourth  lime  she 
was  accompanied  by  her  mother  and  we  were  success- 
ful. In  less  than  five  minutes  she  was  putting  on  her 
hat  unassisted,  only  a  few  administrations  being  neces- 
sary, and  there  was  no  pain  whatever,  and  this  tiie 
same  patient  that  required  two  hours  to  anaesthetize 
previously. 

The  second  case  is  that  of  a  very  stout  patient 
almost  as  broad  as  she  was  tall,  weighing  about  two 
hundred  pounds,  a  patient  in  which  chloroform  ordin- 
arily would  be  contra-indicated.  She  remarked,  'T 
have  four  teeth  to  be  extracted  and  I  knew^  that  you 
would  not  give  me  chloroform  so  I  brought  it  with 

me  and  this  is  Miss ,  a  trained  nurse,  and  she  will 

administer  it."  1  placed  her  in  the  chair  and  explained 
to  her  that  she  must  take  chloroform  my  way  or  not 
at  all.  1  poured  about  three  drams  of  chloroform  from 
a  new  pound  bottle  into  an  empty  mori)hine  bottle 
covered  with  blue  paper — the  one  presented  to  me  by 
Dr.  Hewett  himself,  the  one  he  used  in  the  presence 
of  the  Iowa  Committee.  The  patient,  seeing  this, 
laughed  heartily,  saying  that  it  \v»nil(l  lake  all  that 
was  in  the  large  bottle  to  put  her  to  sleep.  I  held  ihc 
bottle  at  some  distance  and  gradually  l)rought  it  closer 
and  closer  to  her  nose  and  she  took  about  twenty 
inhalations,  and  I  extracted  the  four  teeth,  without 
the  slightest  pain.     As  she  leaned  forward  to  free  her 


356  General  Ancesthetics  in  Dentistry, 

mouth  of  blood,  she  remarked,  "Why  don't  the  physi- 
cians give  it  this  way?"  Then  she  added,  "I  have 
taken  anaesthetics  twelve  times  for  various  surgical 
operations,  but  if  I  ever  have  to  take  it  again,  even 
if  I  am  in  New  York  City,  I  am  going  to  send  for 
you  and  have  you  give  it  your  way." 


General  Amcsthctics  in  Dentistry.  357 


LECTURE  XXL 

Ether  and  Chloroform. 

I  shall  not  devote  very  much  time  or  space  to  ether 
and  chloroform,  because,  in  my  opinion,  these  agents 
should  not  be  used  by  the  dental  surgeon  to  induce 
surgical  anaesthesia.  The  dental  surgeon  is  fortunate 
who  refuses  absolutely  to  allow  these  anaesthetic 
agents  to  be  administered  in  his  office  to  induce  surgi- 
cal anaesthesia.  A  busy  practitioner  can  not  or  should 
not  be  annoyed  and  delayed  and  disarranged  by  turn- 
ing his  operating-room  for  the  time  being  into  a  hos- 
pital. Of  course,  a  dental  surgeon  should  not  adminis- 
ter ether  or  chloroform  for  surgical  anaesthesia  under 
any  circumstances  without  the  aid  and  presence  of 
a  medical  practitioner.  A  physician  only  in  the 
extremest  emergency,  would  be  justified  in  administer- 
mg  ether  or  chloroform  without  the  presence  of 
another  physician. 

We  have  at  our  command  three  very  excellent 
anaesthetic  agents,  nitrous  oxid,  ethyl  chloride  and 
somnoform.  These  anaesthetics  may  very  appropri- 
ately be  designated  office  anaesthetics  in  contra-dis- 
tinction  to  ether  and  chloroform,  which  may  properly 
be  referred  to  as  hospital  anaesthetics. 

The  line  must  be  drawn  somewhere,  and,  in  my 


358  General  Anesthetics  in  Dentistry. 

opinion,  it  should  be  drawn  just  here.  Let  the  dental 
practitioner  confine  himself  to  the  anaesthetics  which 
I  have  designated  office  anaesthetics,  and  turn  over 
to  the  physician  all  cases  in  which  ether  and  chloro- 
form   are    necessary. 

This  is  the  rule  by  which  I  work  in  my  anaesthetic 
practice.  All  cases  in  which  I  am  satisfied  the  office 
anaesthetics  are   not  indicated  go  to  the  hospital. 

If  the  patient  is  so  situated  that  a  hospital  is  out 
of  the  question,  then  the  next  best  place  is  the  office 
of  the  physician  who  is  to  administer  the  anaesthetic. 
He  will  in  all  probability  have  a  good  surgical  table, 
good  light,  and  the  conveniences  that  go  hand  in  hand 
with  anaesthetic  administration,  and  a  good  assistant 
or  a  nurse  to  care  for  the  patient  after  the  operation. 
Probably  in  thirty  minutes  you  can  return  to  your 
office  ready  for  business. 

Should  the  anaesthetic  be  administered  in  your 
office,  patients  will  be  dropping  in  at  an  inopportune 
time.  The  struggling  and  excitement  incident  to  the 
anaesthetic  makes  it  embarrasing  for  those  waiting  and 
on  such  occasions  patients  are  always  numerous. 
Vomiting  and  sickness  nearly  always  follow  ether  and 
chloroform  anaesthesia,  which  is  disgusting  and  nau- 
seating to  those  waiting  their  turn.  You  can't  hurry 
the  patient  out  of  the  office,  and  two  or  three  hours 
of  valuable  time  are  consumed  as  against  a  few  min- 
utes wlien  the  anaesthetic  is  administered  outside  of 
the   office. 

If  the  physician  will  not  permit  the  use  of  his 
office,  then  arrange  to  go  to  the  home  of  the  patient. 


General  Anasthetics  in  Dentistry.  259 

There  are  many  objections  to  this,  I  know,  in  the 
way  of  a  poor  Hght,  the  back-breaking  process  of 
operating  on  a  couch  or  a  bed,  yet,  with  these  incon- 
veniences, when  you  are  through  operating  you  can 
excuse  yourself  and  return  to  your  office.  It  is  the 
anaesthetists  duty  to  remain  and  care  for  the  patient. 

I  have  practiced  in  the  small  town,  and  I  know 
exactly  the  conditions  prevailing  there,  and  it  is  quite 
different  from  a  city  practice.  I  have  had  patients 
come  twenty  miles  without  a  word  of  warning  to  have 
a  "mouthful  of  teeth"  extracted,  when  already  enough 
work  was  engaged  for  that  day  to  keep  three  men 
busy  and  what  is  to  be  done  in  such  cases?  If  located 
in'  a  town  or  village  in  which  there  is  no  hospital,  yet 
on  certain  occasions  it  is  imperative  to  have  chloro- 
form or  ether  administered  in  the  office,  I  would  sug- 
gest the  following  plan :  Procure  a  surgical  chair. 
These  chairs  are  not  very  expensive  and  they  are  very 
useful.  This  surgical  chair  can  be  used  as  a  second 
chair  when  the  operating-chair  is  occupied  for  mak- 
ing examinations,  treating  a  tooth,  taking  a  bite, 
extracting  a  tooth,  etc.,  and  when  needed  can  be  con- 
verted into  an  operating-table. 

There  should  be  a  private  r<iom  for  this  anaesthetic 
work,  and,  when  occasion  arose  to  administer  chloro- 
form or  ether,  roll  the  surgical  chair  into  this  room. 

In  the  year  1906,  there  were  thirty  chloroform 
deaths  reported  that  occurred  in  dental  chairs.  The 
modern  dental  chair  is  not  a  good  enassthetic  chair 
and  in  procuring  a  surgical  chair  you  have  done  much 
to   insure   safety.     No   patient   should   take    ether   or 


260  General  Aiiccsthetics  in  Dentistrv. 

chloroform  with  their  clothing  on.  Especially  in  the 
case  of  women,  everything  should  be  removed  in  the 
way  of  clothing  and  a  night-gown  substituted.  You 
can  provide  gowns  for  this  purpose,  or  the  patient 
would  probably  prefer  to  bring  one  of  her  own  if  you 
have  an  opportunity  in  advance  to  suggest  it. 

You  have  done  now  all  that  would  be  done  at  a 
modern  hospital  in  this  respect.  A  clean  sheet  should 
be  used  for  a  covering  and  your  patient  takes  her  place 
on  the  table. 

Always  have  the  best  anaesthetist  in  the  county, 
and  always  have  the  same  one  if  possible.  If  there 
is  a  professional  nurse  in  the  town,  have  her,  by  all 
means. 

When  the  operation  is  over,  the  nurse  will  relieve 
you  of  all  further  care  and  will  remain  with  the  patient 
while  you  take  up  the   appointments  of  the   day. 

The  nurse  can  make  herself  useful  in  making  the 
patient  comfortable,  and  at  the  proper  time  assist 
her  to  dress,  and  the  patient  leaves  the  office  not  all 
blood-stained  and  nausea-soaked,  as  is  too  often  the 
case  at  the  present  time. 

Remember  that,  when  ether  and  chloroform  are 
the  anjesthetics  employed,  you  are  the  surgeon,  not 
the  auccsthetist,  and  should  not  assume  the  anaesthetic 
responsibihty. 

Perfect  yourselves  in  the  administration  of  nitrous 
oxid  and  somnoform;  it  is  seldom  necessary  to  resort 
to  ether  or  chloroform.  T  had  rather  make  two  or 
three  nitrous  oxid  or  somnoform  administrations  for 
the  same  patient  on  as  many  different  days  than  to 


General  Anccsthctics  in  Dentistry.  261 

have  ether  or  chloroform  administered  in  my  office, 
and  I  am  confident  such  an  arrangement  is  much  better 
for  the  patient. 

Dr.  Teter,  of  Cleveland,  and  others  have  become 
so  proficient  in  the  use  of  nitrous  oxid  and  oxygen 
as  to  make  unnecessary  the  employment  of  any  other 
anaesthetic  agent,  no  matter  what  the  operation  or  how 
long  a  time  it  may  consume. 

Occasions  arise,  especially  in  small  towns  and  vil- 
lages, in  which  it  becomes  necessary  to  have  chloro- 
form or  ether  administered  in  the  oflfice  of  the  dentist 
and  there  is  no  way  to  avoid  it.  It  is  well  to  bear 
in  mind,  that,  on  the  average,  ether  is  seven  times 
less  dangerous  than  chloroform.  It  is  no  unusual 
occurrence  to  pick  up  a  newspaper  and  see  recorded 
there  a  death  in  some  dental  offtce  resulting  from  the 
administration  of  chloroform  for  the  purpose  of  tooth 
extraction,  but  I  can  not  recall  ever  seeing  recorded 
in  the  pul:)lic  press  a  death  from  ether  in  the  dental 
chair. 

While  the  choice  of  the  anaesthetic  to  be  employed 
is  really  a  matter  for  the  anaesthetist  to  settle  with  the 
patient,  the  dental  surgeon  usually  has  an  opportunity 
to  talk  the  case  over  with  the  patient,  before  the  anaes- 
thetist is  selected  or  consulted  in  the  matter.  In  this 
conversation  you  can  say,  "Yes,  it  is -necessary  to  take 
ether.  Whom  do  you  wish  to  administer  the  ether?" 
The  patient  usually  has  a  preference ;  if  not,  you  must 
select  an  anaesthetist  and  make  the  arrangement.  Hav- 
ing agreed  upon  the  anaesthetist,  call  the  physician 
over  the  'pht)ne  and  say  something  like  this:  "Mrs.  A — 


262  General  Ancesthetics  in  Dentistry. 

is  here  at  my  office,  doctor,  and  wishes  you  to  admin- 
ister ether."  The  probability  is,  that  will  decide  the 
anaesthetic  agent  to  be  used  in  this  case,  unless  the 
physician  knows  to  a  certainty  that  ether  is  contra- 
indicated,  and  if  it  is,  of  course  you  want  to  know 
it.  The  patient  might  have  some  pathologic  condition 
of  the  kidneys  or  lungs  that  the  physician  knew  about 
and  you  did  not. 

If  you  leave  the  matter  entirely  in  the  hands  of 
the  physician,  making  no  suggestion  whatever,  he 
might  select  chloroform ;  while,  if  you  intimate  that 
ether  is  to  be  the  anaesthetic,  he  takes  it  for  granted 
and  administers  ether.  Thus  you  can  usually  have 
your  choice  of  the  anaesthetic  agent  to  be  used  in  your 
office  without  apparently  having  any  part  in  the  selec- 
tion of  the  anaesthetic. 

While  the  anaesthetist  is  responsible  for  the  life 
of  the  patient',  should  an  anaesthetic  death  occur  in 
your  office,  your  name  is  always  associated  with  the 
mortality,  a  notoriety  to  be  avoided,  and  for  this 
reason,  you  should  be  interested  in  having  the  safest 
anaesthetic  agent  used  in  every  case. 

If  you  permit  ether  and  chloroform  to  be  admin- 
istered in  your  office,  you  should  familiarize  yourself 
with  the  physiological  action  of  ether  and  chloroform. 
More  than  this,  you  should  know  and  be  able  to  recog- 
nize the  slightest  abnormality  on  the  part  of  the 
patient.  Aid  the  anaesthetist  in  every  possible  man- 
ner. Make  a  study  of  respiration  and  circulation. 
Know  the  various  anaesthetic  stages.  Anticipate  what 
might  happen.     From  your  position  you   may  detect 


General  ArKTsthctics  in  Dentistry.  263 

something  the  anaesthetist,  busy  with  adding  more  of 
the  anaesthetic  agent  from  time  to  time,  has  not 
observed,  and  can  call  his  attention  to  it.  As  long  as 
everything  progresses  satisfactorily,  he  may  not  need 
your  assistance,  but  if  things  go  wrong  he  will  need 
you,  and  need  you  badly.  This  is  no  time  for  instruct- 
ing you  how  to  do  things,  you  should  know  how,  and 
pitch  in  and  help.  Remember  it  is  your  ofhce  and  your 
patient,  and  partly  your  responsibility. 

You  should  know  the  various  measures  and  reme- 
dies employed  for  resuscitation  and  understand  artifi- 
cial respiration.  The  anaesthetist  may  become  rattled 
and  not  equal  to  the  emergency,  and  your  services 
needed  to  save  the  life  of  the  patient. 

You  should  know  how  to  administer  ether  and  how 
to  administer  chloroform  if  you  permit  their  use  in 
your  office.  Knowing  how  to  administer  these  agents 
gives  you  an  advantage  as  an  assistant.  If  the  anaes- 
thetist becomes  careless,  hurries  or  takes  unusual  risks, 
you  observing  this,  are  in  a  position  to  anticipate  what 
will  happen,  and  are  ready  for  the  emergency  that  may 
arise.  Good  anaesthetists  are  rare,  and  simply  because 
a  man  has  the  AI.  D.  degree  he  is  not  necessarily  a 
competent  anaesthetist,  especially  in  the  smaller  towns 
and  villages  where  it  is  sometimes  necessary  to  take 
the  physician  that  docs  not  hapi)en  to  be  busy.  A 
man  becomes  rusty  and  deficient  in  administering 
anaesthetics  just  as  in  anything  else;  so.  when  you 
can  possibly  do  so,  employ  the  man  in  your  community 
that  has  the  largest  anaesthetic  practice. 


264  General  Ancesthetics  in  Dentistry. 

Sulphuric  Ether. 

Valerius  Cordus  discovered  sulphuric  ether  in  1540, 
but  not  till  three  centuries  later  were  its  anaesthetic 
properties  recognized  by  Morton,  an  American  dentist, 
in  the  year  1846. 

Sulphuric  ether,  vinous  ether,  ethylic  ether  has  the 
chemical  formula  C^H^eO. 

Ether  is  a  transparent,  colorless,  highly  volatile  and 
inflammable  fluid  with  a  pungent  odor  and  a  burning 
taste.     It  mixes  freely  with  alcohol   and   chloroform. 

It  is  important  to  remember  that  ether  is  highly 
inflammable  and  burns  with  a  white  luminous  flame. 
It  should  never  be  administered  in  a  room  that  is 
lighted  with  a  candle,  lamp,  gas  jet  or  any  kind  of  an 
open  flame.  Actual  cautery  must  not  be  used  about 
the  m.outh  or  nose  when  ether  is  being  administered. 
Cases  are  on  record  in  which  the  patient  has  been 
severely  burned,  the  inhaler  igniting  and  the  face 
burned  deeply,  involving  the  nose,  throat  and  lungs, 
when    actual   cautery   was    used. 

There  are  two  methods  of  administering  ether ;  one 
is  known  as  the  "close,"  and  the  other,  the  "open" 
method. 

The  close  method  is  used  almost  universally  abroad, 
while  the  open  method  is  used  almost  exclusively  in 
this  country.  It  is  difficult  to  understand  why  this 
should  l)C,  yet  it  is  a  matter  of  history.  Still  more 
mysterious  is  the  fact  that  the  highest  anaesthetic 
authorities    in    both    Entrland    and    Scotland    maintain 


General  Anaesthetics  in  Dentistry.  265 

that  a  satisfactory  anaesthesia  can  not  be  induced  by 
the   open    method. 

Hewitt  says,  "As  a  general  rule,  it  is  impossible 
to  produce  deep  anaesthesia  by  this  (the  open)  system, 
although  it  may  be  used  in  infants,  in  extremely  ex- 
hausted subjects,  or  in  ])atients  who  ha\-c  been  lor 
some  time  deeply  anaesthetized,  and  who,  in  conse- 
quence,  require   minimal    insensibility." 

Luke,  of  Edinburgh,  in  the  British  Medical  Journal 
of  March  17,  1906,  writes:  "An  American  surgeon  on 
a  visit  to  this  country  recently  told  me  that  a  lady  gave 
his  anaesthetics  for  him,  combining  this  duty  with 
typewriting  and  stenography.  She  possessed  no  medi- 
cal qualification  of  any  description.  I  inquired  as  to 
the  method  she  adopted,  and  was  told  she  gave  ether 
in  all  cases  by  the  drop  method,  on  an  open  mask, 
and  apparently  the  results  were  most  satsfactory. 
While  ready  to  believe  that  there  were  but  few 
fatalities  when  such  a  method  was  employed,  I  at 
once  came  to  the  conclusion  that  neither  he  or  the 
lady  had  much  conception  of  what  anaesthesia  really 
meant  for  everyone  who  knows  anything  of  the  sub- 
ject must  be  aware  that  it  is  morally  impossible  to 
produce  satisfactory  anaesthesia  in  adults  by  such  a 
method  with  ether  unless  morphine  or  scopolamine  is 
called  into  requisition  as  an  adjunct."  The  open 
method  here  referred  to  is  used  all  over  the  L'nited 
States  hundreds  of  times  a  day.  yet  these  eminent 
authorities  deny  that  satisfactory  anaesthesia  can  be 
induced   by   the  drop   method  of  administering  ether. 


266  General  Ancesthetics  in  Dentistry. 

I  doubt  if  you  ever  have  or  ever  will  witness  any  other 
than   the   drop   method    in   this   country. 

The  patient  should  be  especially  prepared  in 
advance  when  ether  or  chloroform  are  to  be  admin- 
istered. The  night  before  the  operation  the  patient 
should  be  given  a  good  dose  of  castor  oil.  This  should 
be  followed  next  morning  by  a  dose  of  salts.  If  the 
operation  is  to  be  performed  next  morning  about  eight 
o'clock,  no  breakfast  should  be  eaten. 

Even  for  my  ether  patients  I  prefer  to  use  a  mouth- 
prop  during  the  administration  of  the  anaesthetic.  For 
this  purpose  I  prefer  the  ordinary  soft  rubber  mouth- 
prop,  thoroughly  sterilized,  about  which  a  string  is 
tied.  In  the  first  and  second  stages  of  ether,  the 
masseter  muscles  frequently  contract,  and,  if  the 
patient  should  happen  to  become  nauseated  to  the 
degree  of  vomiting  at  this  time  or  the  tongue  be 
swallowed,  the  situation  might  become  a  serious 
one.  Another  reason  is  this :  the  masseter  muscle 
is  sometimes  the  last  one  in  the  body  to  relax.  Surgical 
anaesthesia  has  already  been  induced  and  there  is  no 
reason  why  the  operation  could  not  be  commenced, 
if  the  mouth  was  only  open.  Frequently  a  depth  of 
anaesthesia  entirely  unnecessary  for  the  operation 
under  consideration  must  be  had  in  order  to  relax 
these  muscles  and  force  the  jaws  apart  sufficiently  wide 
for  the  operation. 

The  face  of  the  patient  should  be  smeared  with 
vaseline.  Ether  is  irritating,  and  if  it  comes  in  con- 
tact with  the  mucous  membrane  it  burns.  Have  the 
patient  close  the  eyes  and   i)lace   over  each   eyelid   a 


General  .liKcstlictics  in  Dentistry.  '^67 

good-sized  piece  of  moist  sterlized  al)sorbcnt  cotton 
or  surgeon's  gauze.  This  is  to  prevent  ether  get- 
ting into  the  eyes.  Then  wrap  a  towel  around  the 
head  well  down  over  the  eyes  almost  to  the  entrance 
of  the  nares.  This  is  to  hold  the  cotton  or  gauze  on 
the  eyes  and  to  protect  the  cheeks.  Fasten  this  towel 
or  surgeon's  bandage  tightly  with  a  safety-pin.  Place 
another  towel  under  the  chin,  bringing  it  well  up  to 
the  lower  lip  and  around  back  of  the  neck.  This  pro- 
tects the  lower  ])art  of  the  face  and  cheeks  also. 

A  good  inhaler  is  the  improved  Esmarch.  This 
should  be  boiled,  of  course,  each  time  after  using  and 
also  before  using.  Two  thicknesses  of  stockinet  are 
used  with  this  inhaler;  and  the  stockinet  destroyed 
after  using.  Prepare  a  cork  for  the  ether  can  with 
a  slit  on  two  sides.  In  one  of  these  slits  or  grooves 
place  a  thin  wick  of  absorbent  cotton  extending  out 
about  an  inch.  Alice  Magaw  recommends  two  cans, 
one  with  a  large  dropper  to  be  used  in  the  beginning 
till  the  patient  is  fully  under  the  anaesthetic,  then 
changed  to  the  can  with  the  small  dropper  to  be  used 
during  the  operation. 

The  patient  must  now  be  handled  as  described  in 
the  "Elements  of  Success"  lecture.  Get  your  patient 
in  a  tranquil  frame  of  mind,  dispel  fear,  suggest  the 
things  you  want  them  to  see  and  feel  so  strongly  that 
they  will  see  and  feel  them.  In  this  frame  of  mind, 
it  does  not  require  much  ether  to  anaesthetize  a  patient 
or  to  maintain  anaesthesia,  I  have  come  to  believe 
the  success  one  attains  in  administering  anaesthetics 
depends  largely   on  the   anaesthetist;  his  personality, 


268  General  Anccsthetics  in  Dentistry. 

his  manner,  the  impression  he  makes  on  the  patient  is 
nine-tenths  the  battle. 

Un  this  point,  Alice  Magaw  says:  "Suggestion  is 
a  great  aid  in  producing  a  comfortable  narcosis.  The 
ansesthetist  must  be  able  to  inspire  confidence  in  the 
patient,  and  a  great  deal  depends  upon  the  manner 
of  approach.  One  must  be  quick  to  notice  the  tem- 
perament, and  decide  which  mode  of  suggestion  will 
be  the  most  effective  in  the  particular  case ;  the  abrupt, 
crude,  and  very  firm,  or  the  reasonable,  sensible  and 
natural.  The  latter  mode  is  far  better  in  the  majority 
of  cases.  The  subconscious  or  secondary  self  is  par- 
ticularly susceptible  to  suggestive  influence;  there- 
fore, during  the  administration,  the  anaesthetist  should 
make  those  suggestions  that  will  be  most  pleasing 
to  this  particular  subject.  Patients  should  be  pre- 
pared for  each  stage  of  the  anaesthesia  with  an  explana- 
tion of  just  how  the  anaesthetic  is  expected  to  afifect 
him;  talk  him  to  sleep,  with  the  addition  of  as  little 
ether  as  possible.  A\'e  have  one  rule  :  Patients  are  not 
allowed  to  talk,  as  by  talking  or  counting,  patients 
are  more  apt  to  become  more  noisy  and  boisterous. 
Never  bid  a  patient  to  'breathe  deep,'  for  in  so  doing 
a  feeling  of  suffocation  is  sure  to  follow,  and  the 
patient  is  also  apt  to  struggle." 

The  amount  of  ether  required  for  a  given  patient 
is  always  an  unknown  (piantity.  The  rule  is  to  give 
the  required  amount  whatever  that  may  be  and  no 
more.  The  temi)crament  of  the  ])atient,  the  mental 
attitude,  the  operation  to  be  performed,  the  time  con- 
sumed in  each  individual  case  to  induce  surgical  anaes- 


General  .hucsthetics  in  Dentistry.  2G\) 

tliesia  all  play  a  part  in  determining  the  amount  of 
ether  necessary  fur  the  case  in  hand. 

The  ether  is  fed  drop  by  drop,  no  attempt  being 
made  to  exclude  air  in  the  beginning".  It  recpiires  a 
deeper  anaesthesia  at  the  time  of  starting  the  operation 
than  later.  Having  induced  surgical  anaesthesia  the 
can  being  used  is  set  aside  and  the  one  with  the  small 
dropper  substituted.  It  requires  but  very  little  ether 
to  maintain  surgical  anaesthesia.  Results  obtained  by 
Alice  Magaw,  anaesthetist  to  St.  Mary's  Hospital, 
Rochester,  Minnesota,  at  the  Mayo  clinic,  are  almost 
beyond  belief.  Ether  is  her  favorite  anaesthetic,  she 
uses  the  open  method  altogther,  and  obtains  surgical 
anaesthesia  in  from  three  to  five  minutes.  The  small 
amount  of  ether  used  by  this  anaesthetist,  as  com- 
pared to  the  quantity  ordinarily  used  by  other  anaes- 
thetists is  astonishing.  In  reply  to  the  question, 
"How  do  you  do  it?""  she  will  make  answer.  "I  simply 
talk  them  to  sleep." 

I  have  maintained  for  years  that  the  administra- 
tion of  anaesthetics  is  not  a  very  dangerous  procedure, 
and  that  when  the  subject  was  better  understood  and 
more  rational  methods  employed  in  administering 
anaesthetics,  a  mortality  would  rarely  occur  as  the 
result  of  the  anccsthelic.  per  se.  Alice  Magaw  is  doing 
a  valiant  serxice  and  everyone  that  visits  Rochester 
to  see  the  Mayos  oi)crate,  are  imi:)ressecl  with  her  mar- 
velous work.  W  ith  a  record  of  18,000  anaesthesias 
she  has  never  had  a  death  as  the  result  of  the  anaes- 
thetic. 

In  regard  to  dangers,  she  says;    "Should  ether  pro- 


270  General  Anccsthctics  in  Dentistry. 

cluce  difficult  breathing,  profuse  secretion  of  mucus, 
or  cough,  lift  the  mask  from  the  face,  allow  a  liberal 
amount  of  air,  and  continue  with  the  ether.  In  giv- 
ing plenty  of  air,  when  needed,  and  less  ansesthetic, 
we  have  found  little  use  for  an  oxygen  tank,  a  loaded 
hypodermic  syringe,  or  tongue  forceps.  It  is  far  bet- 
ter for  the  anaesthetist  to  become  skillful  in  watching 
for  symptoms  and  prevent  them,  than  to  become  so 
proficient  in  the  use  of  the  three  articles  mentioned." 
Every  precaution  should  be  taken  in  the  adminis- 
tration of  ether  to  admit  air  freely.  Proper  elevation 
of  the  head  has  much  to  do  with  the  admission  of 
exclusion  of  air.  "Proper  elevation  of  the  head  will 
relax  all  tissues  of  the  neck  and  give  more  freedom 
in  breathing.  This  also  can  be  said  of  the  jaw.  Hold- 
ing the  jaw  up  and  forward  and  keeping  it  in  posi- 
tion so  that  the  patient  gets  the  greatest  amount  of 
air  possible  is  an  important  feature  in  giving  an  anaes- 
thetic. 

Chloroform. 

Sir  James  Y.  Simpson  was  the  first  to  call  atten- 
tion to  the  anaesthetic  properties  of  chloroform.  He 
was  one  of  the  first  to  make  use  of  ether  as  an  anaes- 
thetic, and,  in  seeking  to  find  some  agent  that  pos- 
sessed the  narcotic  properties  of  ether,  yet  was  less 
irritating  and  more  pleasant  to  inhale,  in  1847,  an- 
nounced chloroform  to  be  that  agent. 

Chloroform  was  hailed  with  delight,  and  enthusi- 
astically received  on  all  sides,  and  at  first  was  thought 
to  be  absolutely  devoid  of  danger.     First  one  death, 


General  Anaesthetics  in  Dentistry.  271 

then  another,  made  surgeons  more  cautious,  and  ether, 
so  nauseating  and  with  all  its  disagreeable  after  ef- 
fects, is  more  universally  employed  than  any  other 
general  anaesthetic. 

It  was  a  great  disappointment  to  everybody  that 
so  many  mortalities  occurred  from  chloroform  anaes- 
thesia, because  its  effects  were  so  much  more  pleasant 
in  every  particular  than  anaesthesia  induced  by  ether, 
and  its  briefer  period  of  induction  was  greatly  in  its 
favor.  I  am  satisfied  that  chloroform  is  not  as  dan- 
gerous an  anaesthetic  as  the  mortalities  following  its 
use  would  indicate.  Some  men  have  made  thousands 
of  chloroform  anaesthesias  and  have  never  seen  a 
chloroform  death.  This  would  seem  to  indicate  that 
some  men  are  either  more  careful  than  others,  or  that 
they  have  a  safer  method  of  inducing  chloroform  anaes- 
thesia. 

When  a  towel  folded  in  the  shape  of  a  cone  was 
used  as  a  chloroform  inhaler,  deaths  were  far  more 
frequent  than  now.  Chloroform  is  nearly  four  times 
as  heavy  as  air  and  when  a  cone  is  used  as  an  in- 
haler, and  held  over  the  nose  and  mouth  patients  are 
drowned.  The  drop  method  should  always  be  em- 
ployed using  an  Esmarch  or  similarly  constructed  in- 
haler. In  the  beginning  the  chloroform  vapor  should 
be  very  mild.  Two  per  cent,  of  chloroform  is  suffi- 
cient to  anaesthetize  a  patient  and  one  per  cent,  is 
all  that  is  needed  to  maintain  anaesthesia.  When  we 
witness  a  chloroform  anaesthesia,  as  the  agent  is 
usually  administered,  it  is  astonishing  that  many  more 
mortalities  do  not  occur.    It  makes  no  difference  how 


272  General  Anccsthetics  in  Dentistry. 

safe  a  given  anaesthetic  agent  may  be  in  the  hands  of 
a  certain  anaesthetist,  the  general  average  of  mor- 
talities occurring  from  the  use  of  an  anaesthetic  is  what 
determines  its  relative  safety.  Judged  in  this  way, 
chloroform  has  a  death  rate  several  times  greater  than 
ether  and  the  latter  agent  for  that  reason  has  become 
more  generally  employed  in  surgical  work. 

Chloroform  was  independently  discovered  by  Guth- 
rie, Liebig  and  Soubeiran  in  the  year  1831,  but  not 
till  1847  was  it  known  to  possess  anaesthetic  proper- 
ties. 

It  is  a  colorless,  volatile  liquid  with  a  penetrating 
odor,  and  sweetish  taste  producing  a  burning  sensa- 
tion. 

For  anaesthetic  purposes,  only  the  purest  makes 
should  be  employed.  It  is  well  to  remember  that 
chloroform  should  be  protected  from  the  light.  Ram- 
say has  made  the  statement  that  chloroform  exposed 
to  the  light  and  air  in  the  course  of  a  short  time  leads 
to  the  formation  of  carbonyl  chloride.  For  this 
reason,  it  is  a  good  plan  to  keep  chloroform  in  a  dark 
place.  Some  manufacturers  with  this  end  in  view  use 
blue  glass  bottles  as  containers.  Others  cover  the 
bottles  containing  chloroform  with  blue  paper,  while 
others  use  tin  can  containers. 

There  are  some  simple  tests  that  should  be  re- 
membered. It  is  a  good  plan  to  purchase  chloroform 
in  quarter-pound  bottles  rather  than  larger-sized  pack- 
ages, and  these  are  not  so  apt  to  change  chemically  or 
become   impure  before   using  as   larger  packages. 


General  Anccsthetics  in  Dentistry.  273 

Pure  chloroform  should  be  absolutely  neutral  to 
litmus  paper. 

It  sIkjuUI  have  a  boiling-point  of  one  hundred  and 
forty  degrees  Fahrenheit. 

It  should  have  a   mild,   non-irritating  odor. 

It  should  be  transparent  and  colorless. 

Shaken  with  sulphuric  acid,  there  should  be  no  dis- 
coloration. 

With  a  solution  of  argentum  nitrate,  it  should  not 
form  a  precipitate. 

When  heated  to  the  boiling-point  with  caustic  pot- 
ash,  it  should   not  show  brown. 

If  placed  on  the  bottom  of  a  tumbler  or  in  a  watch 
crystal  and  allowed  to  evaporate,  it  Sliould  leave  no 
residue. 

To  be  absolutely  safe,  it  is  better  to  open  a  fresh 
original  package  each  time  than  to  take  the  slightest 
risk  of  using  a  bottle  that  has  been  standing  around. 
Chloroform  is  not  expensive  and  no  risks  should  be 
assumed.  The  patient  should  be  prepared  in  advance 
for  chloroform  administration,  and  all  that  has  been 
said  in  regard  to  preparation  of  the  patient  when  ether 
was  to  be  taken,  is  applicable  here.  This  is  more  than 
true  in  regard  to  protecting  the  eyes  and  cheeks  from 
having  chloroform  accidentally  come  in  contact  with 
them,  because  it  is  a  stronger  irritant  than  ether  and 
unfortunately  some  patients  have  been  badly  burned 
from  the  liquid  chloroform  coming  in  contact  with  the 
face  and  eyes. 

If  you  are  aware  at  any  time  of  chloroform  or  ether 
getting  into  the  eye,  follow  it  with  a  drop  of  sweet 


27-i  General  Anccsthetics  in  Dentistry. 

oil.  This  will  prevent  conjunctivitis.  The  position 
of  the  patient  is  a  very  important  thing  in  chloroform 
anaesthesia.  The  sitting  posture  should  never  be  al- 
lowed in  chloroform  narcosis.  The  patient  should  be 
placed  on  his  back,  his  head  being  on  a  level  with 
the  body  or  only  slightly  elevated.  There  is  a  dimin- 
ution of  blood  pressure  in  chloroform  anaesthesia,  and 
it  is  important  that  the  heart  be  saved  as  much  work 
or  effort  as  possible,  and  it  is  self-evident  the  more 
nearly  erect  the  posture  of  the  patient  the  harder  the 
heart  must  pump  to  supply  blood  to  the  brain.  Anaemia 
of  the  brain  is  one  of  the  causes  of  circulatory  arrest. 

Even  if  the  patient  has  been  placed  in  the  correct 
anaesthetic  position  for  chloroform  administration,  if 
the  operation  is  that  of  extracting  teeth,  when  ready 
to  operate,  if  the  chair  is  raised  to  a  position  conven- 
ient for  the  operator,  it  is  always  done  at  great  risk. 
If  the  heart  is  unable  to  respond,  or  if  the  task  is  met 
by  an  effort,  the  imposed  strain  to  meet  the  conditions 
may  be  such  as  to  result  in  heart  failure. 

Remember  this:  if  chloroform  should  be  admin- 
istered in  your  office  for  the  purpose  of  tooth  extrac- 
tion, no  matter  how  much  the  position  of  the  patient 
may  inconvenience  you,  if  it  is  possible  to  do  so, 
operate  without  raising  the  head  at  all;  but,  if  the 
head  must  be  raised,  see  to  it  that  it  is  raised  not  one 
inch  higher  than  necessary.  I  believe  that  many  of 
the  mortalities  occurring  in  dental  chairs  as  a  result 
of  chloroform  anaesthesia  are  really  caused  by  having 
the  head  of  the  patient  unduly  elevated  during  the 


General  AncFsthctics  in  Dentistry.  275 

induction  of  the  anaesthesia,  or  by  suddenly  elevating 
the  chair  to  the  ordinary  extracting  position. 

When  we  take  into  consideration  that  the  clothing 
of  the  patient  is  rarely,  if  ever,  removed  when  chloro- 
form is  administered  in  a  dental  chair,  or  that  any 
preliminary  physical  preparation  has  been  made,  and 
that  little  or  no  attention  is  paid  to  the  position  of 
the  patient  in  the  chair,  and  further,  when  surgical 
anaesthesia  has  been  induced,  the  back  of  the  chair  is 
raised  with  a  jerk,  bringing  the  patient  suddenly  to 
the  sitting  posture,  it  is  not  surprising  that  so  many 
chloroform  mortalities  occur  in  the  dental  office.  If 
the  dental  surgeon  makes  no  other  preparation  than 
the  dental  chair  in  his  office  for  the  administration 
of  chloroform,  for  the  sake  of  the  patient,  for  your 
own  sake,  and  for  the  sake  of  chloroform  itself,  refuse 
absolutely  to  permit  this  anaesthetic  to  be  adminis- 
tered in  your  office  for  the  operation  of  tooth  extrac- 
tion. 

The  eyes  and  cheeks  having  been  properly  pro- 
tected, the  patient  placed  in  the  chloroform  position, 
the  anaesthetist  assumes  a  comfortable  position,  and 
takes  the  Esmarch  or  other  inhaler  in  hand,  and,  by 
means  of  the  drop  method,  induces  anaesthesia.  The 
milder  the  better  in  the  beginning,  gradually  increas- 
ing the  amount  as  the  patient   is  ready   for  it. 

Hewitt,  of  London,  has  prepared  the  most  accurate 
and  \alual)le  tal)le  I  have  ever  seen,  setting  forth  the 
degrees  or  stages  of  anaesthesia,  and  I  recduimentl 
that  it  be  studied  closely. 

The  treatment  of  accidents  or  dangers  arisinii  dur- 


2T6  General  Anesthetics  in  Dentistry. 

iiig  ether  and  chloroform  ansesthesia  will  be  found 
in  the  lecture  entitled  "Difficulties  and  Dangers  Inci- 
dent to  Administering  General  Anaesthetics  in  Dental 
Practice  and  How  to  Meet  Them." 

Dr.  Frederick  W.  Hewitt's  Table,  Showing  the  De- 
grees or  Stages  in  the  Action  of  the  Chief  General 
Anaesthetics  Upon  the  Human  Organism,  and  the 
Phenomena  Which  Usually  Characterize  These 
Stages  When  No  Complication,  Asphyxial  or 
Traumatic,  Is  Present. 

Effects. 
1.     Stage  of  Analgesia. 

Excessive  ideation;  disturbances  of  judgment,  con- 
trol, and  volition. 

Analgesia. 

Vertigo  and  loss  of  power  of  maintaining  equilib- 
rium. 

Pleasurable  or  distressing  sensations. 

Disturbances  (exaggeration  or  diminution)  of  com- 
mon sensibility  and  of  special  senses. 

Misinterpretation  of  external  impressions. 

Emotional  disturbances;  e.  g.,  laughter  and  crying. 

Reflexes  well  marked  and  often  exaggerated ;  sen- 
sory stimuli  produce  co-ordinated  and  apparently  pur- 
posive movements. 

Loss  of  power  and  remembering  (fixing)  sensory 
impressions. 

Dreams. 

Rise  of  blood-pressure  and  increase  of  cardiac 
action. 


General  Anesthetics  in  Dentistry.  277 

Respiration  increased  but  regular  and  free,  unless 
interfered  with  by  emotional  causes  or  by  direct  irri- 
tation of  the  anaesthetic,  inducing  cough,  "holding  of 
breath,"  deglutition  movements,  retching  or  vomiting. 

Pupils  dilated. 

2.     Stage  of  Light  Anaesthesia. 

Complete  loss  of  consciousness. 

Delirium  ;  articulate  speech  passing  into  unintelli- 
gible muttering. 

Respiration  still  deeper  and  quicker  than  normal ; 
often  irregular  and  impeded  by 

General  tonic  muscular  spasm,  deglutition,  closure 
of  glottis,  spasm  of  jaws,  etc. 

Clonic  muscular  spasm. 

Reflexes  still  persist ;  but  motor  results  of  stimuli 
devoid  of  purposive  character. 

Inarticulate  phonated  (expiratory)  sounds. 

Coughing,  retching,  vomiting. 

Heart's  action  still  excited  (much  dependent  on 
character  of  breathing). 

Pupils  smaller. 

3,     Stage  of  Deep  Anaesthesia  or  Narcosis. 

Relaxation  of  most  muscles. 

Breathing  regular,  often  softly  snoring  or  ster- 
torous. 

Decrease  of  respiratory  changes;  fall  of  temper- 
ature. 

Increase  fall  of  blood-pressure.     (Chloroform.) 

Heart's  action  weakened,  variable  degree  of  cardiac 
dilitation. 


378  General  Ancrsthetics  in  Dentistry. 

Loss  of  corneal,  pharyngeal,  laryngeal,  patellar,  and 
most  but  not  all  reflexes. 
Pupils  larger. 

4.     Stage  of  Bulbar  Paralysis. 

Loss  of  bladder  distension,  rectal,  and  other  very 
late  (e.  g.,  certain  peritoneal)  reflexes. 

Breathing  becomes  shallow. 

Increased  lividity  or  pallor. 

Breathing  ceases  (paralysis  of  respiratory  centers), 
loss  of  respiratory  reflexes. 

Paralysis  of  vaso-motor  centers. 

Feeble,  irregular  cardiac  action,  complete  cardio- 
vascular paralysis. 

Widely  dilated  pupils. 

Separation  of  eyelids. 

Death. 


General  Aiucstlietics  in  Dentistry.  279 


LECTURE  XXII. 

Difficulties   and    Dangers    Incident   to    Administering 

General  Anaesthetics  in  Dental  Practice  and 

How  to  Meet  Them. 

One  of  the  most  trying  things  connected  with  anaes- 
thetic administration  is  the  condition  of  fear  or  dread 
on  the  part  of  the  patient.  The  more  frightened  the 
patient,  the  more  difficult  it  is  to  successfully  anaesthet- 
ize the  patient.  As  I  have  already  said  in  a  previous 
lecture,  I  nnich  prefer  to  anaesthetize  a  patient  with 
an  impaired  kidney,  a  diseased  lung  and  an  abnormal 
heart  in  a  tranquil  state  of  mind,  devoid  of  fear,  than 
to  administer  an  anaesthetic  to  a  patient  perfectly 
health}'  who  takes  the  chair  trembling  with  fear.  To 
dispel  fear  is  the  duty  of  every  anaesthetist,  and  we 
have  already  spoken  of  this  at  some  length  in  the  lec- 
ture on  "Elements  of  Success." 

One  of  the  most  difficult  things  about  an  ansesthetic 
practice  in  dentistry  is  to  get  the  women  to  remove 
their  corsets.  They  will  insist  that  the  corset  is  very, 
very  loose  and  there  is  no  necessity  of  even  making  it 
looser,  and  as  to  removing  it  they  often  refuse  to  do  so 
at  first,  and  then  only  under  protest  when  informed 
that  I  will  not  operate  for  them  unless  the  corset  is 
removed.     This  is  a  rule  that  should  be  insisted  upon 


280  General  Ancesthetics  in  Dentistry. 

and  never  violated.  In  making  an  appointment,  you 
will  do  well  to  remind  patients  that  the  corset  must 
be  removed  and  request  them  to  come  dressed  loosely, 
and  many  will  take  the  hint  and  not  wear  a  corset  to 
the  office.  In  speaking  of  this,  on  one  occasion,  at  a 
dental  clinic,  Dr.  McClanahan,  of  Iowa  Falls,  told  me 
that  he  had  a  patient  that  insisted  that  her  corset  was 
very  loose  and  he  took  her  word  for  it.  This  patient 
as  he  administered  the  ansesthetic  breathed  imperfectly 
and  then  ceased  to  breathe.  This  "loose  corset"  was  so 
tight  that  the  doctor  with  all  his  strength  could  not 
force  it  together  to  unhook  it  and  was  compelled  to 
cut  the  string  with  a  knife,  and  the  patient  breathed 
again. 

The  corset  question  has  also  been  more  thoroughly 
considered  in  the  lecture  on  "Elements  of  Success." 
But  let  me  say  just  here,  that  many  dentists  have 
marvelled  at  the  very  few  nausea  cases  that  I  have 
reported  in  my  practice,  only  about  a  dozen  in  more 
than  6,000  somnoform  anaesthesias,  where  blood  has 
not  been  swallowed.  I  account  for  this  not  altogether, 
but  largely  because  my  patients  are  anaesthetized  with- 
out their  corsets. 

Little  children  nearly  always  rebel  and  cry  just  as 
you  attempt  to  insert  the  mouth-prop.  This  is  always 
unfortunate,  but  can  not  be  helped.  I  prefer  somno- 
form to  nitrous  oxid  as  an  ansesthetic  for  little  chil- 
dren. One  reason  is  that  with  nitrous  oxid  the  time 
and  attention  of  the  assistant  is  entirely  taken  up  in 
looking  after  the  anaesthetic,  while  with  somnoform 
the  assistant  has  nothing  to  do  but  to  help  with  the 


General  Ancosthetics  in  Dentistry.  281 

patient.  The  little  patient,  becoming  nervous  and  re- 
belling, really  needs  someone  who  understands  how  to 
keep  her  from  sliding  down  in  the  chair  and  getting 
away  from  you,  or  to  keep  the  hands  from  grabbing 
the  inhaler  or  steady  the  head  as  it  is  turned  violently 
form  one  side  to  the  other.  With  nitrous  oxid,  the 
assistant  having  all  she  can  attend  to,  especially  if 
oxygen  is  to  be  used  with  the  nitrous  oxid,  the  parent 
or  some  friend  has  to  assist  in  holding  the  patient  and 
this  should  never  be  permitted  when  nitrous  oxid  is 
the  anaesthetic  agent  employed.  As  soon  as  the  patient 
becomes  a  little  cyanotic,  the  friend  or  parent,  which- 
ever it  may  be,  frequently  becomes  hysterical,  thinking 
the  child  is  dying,  insists  that  you  discontinue,  and  if 
you  do  and  extract,  then  the  child  yells  and  screams 
as  loud  as  she  can,  then  the  mother  contends  that 
you  not  only  nearly  killed  the  child  with  the  anaesthetic 
but  that  you  hurt  her  besides.  In  administering  nitrous 
oxid,  no  member  of  the  family  or  near  relative  should 
be  allowed  to  stand  where  they  can  see  the  patient. 
It  is  much  better  that  they  should  not  be  allowed  even 
in  the  operating-room.  When  I  am  using  somnoform, 
I  prefer  the  parents  or  friends  to  remain  near  the  pa- 
tient till  1  am  ready  to  begin  to  extract.  At  the  nod 
of  my  head,  as  i)reviously  arranged,  the  mother 
leaves  the  room,  and  I  call  her  as  soon  as  the  ex- 
tracting is  completed  and  have  her  stand  in  front  of 
the  little  patient  so  she  will  see  her  as  soon  as  she  is 
suflficiently  awake.  Under  somnoform  anaesthesia,  the 
patient  has  a  quiet,  sleeplike  appearance,  beautiful  to 
behold  and  the  parent  seeing  the  child  sleeping  away 


/ 


282  General  Anecsthctics  in  Dentistry. 

so  beautifully  is  not  as  apprehensive  of  fear  or  does 
she  suffer  as  much  anxiety  as  when  she  does  not  know 
what  is  being  done  or  going  on.  To  return  to  the  pa- 
tient again,  I  said  when  you  begin  to  insert  the  mouth- 
prop  the  patient  often  rebels  and  cries  aloud  attempt- 
ing to  get  his  liberty.  Somnoform  is  supreme  in  these 
cases,  for  it  only  takes  a  very  little  of  it  to  quiet  the 
patient,  usually  one  inhalation  and  all  crying  is  over 
and  the  anaesthesia  progresses  evenly  without  a 
struggle. 

Whether  using  nitrous  oxid  or  somnoform,  you 
must  be  careful  with  crying  children.  Some  children 
hold  their  breath  as  long  as  they  can,  then  exhale, 
which  is  followed  by  a  very  deep  inhalation.  Here  is 
a  danger  point  no  matter  what  the  anaesthetic.  With 
chloroform  vapor,  enough  might  be  inhaled  at  that 
one  inhalation  to  cause  paralysis  of  the  respiration  or 
circulation.  The  same  is  true  of  somnoform.  Hewitt 
says  the  greatest  care  must  be  exercised  just  here 
when  nitrous  oxid  is  the  anaesthetic  agent  lest  the  pa- 
tient become  dangerously  asphyxiated. 

At  this  first  inhalation,  after  the  breath  has  been 
held,  no  matter  what  anaesthetic  agent  is  being  used, 
be  sure  that  only  a  small  part  of  the  anaesthetic  vapor 
be  allowed  to  enter  the  lungs.  With  chloroform,  ether 
or  nitrous  oxid  as  usually  administered,  the  amount 
of  anaesthetic  inhaled  at  this  first  inhalation  is  a  matter 
of  guess-work.  With  the  DeFord  inhaler,  the  amount 
of  ethyl  chloride,  somnoform  or  nitrous  oxid  can  be 
gauged  to  a  nicety.  With  the  inhaler  held  tightly 
against  the  face  you  can  adjust  the  appliance  so  as  to 


General  Ancesthctics  in  Dentistry.  283 

admit  just  as  small  an  amount  of  the  ancesthetic  as 
you  desire.  Or,  at  this  first  inhalation,  if  using  the 
DeFord  inhaler,  you  can  exclude  all  anaesthetic  and 
the  patient  inhales  all  air,  and  at  the  next  inhalation  or 
even  the  next  after  that,  when  the  patient  is  not  breath- 
ing so  deeply,  just  a  trace  can  be  admitted.  Enough 
goes  along  with  this  first  inhalation,  if  the  anaesthetic 
is  somnoform  or  ethyl  chloride,  to  quiet  the  patient, 
and  the  breathing  becomes  regular  and  there  is  seldom 
any  further  trouble ;  but,  if  nitrous  oxid  is  the  anaes- 
thetic agent  being  used,  the  first  two  or  three  inhala- 
tions stimulates  the  patient  and  makes  him  more  dif- 
ficult to  control. 

The  following  case  is  illustrative  of  what  can  be 
done  in  these  cases  of  nervous  children.  Not  very 
long  ago  I  was  asked  to  administer  somnoform  for  Dr. 
W —  at  Drake  University  Medical  College,  the  opera- 
tion being  a  double  tonsilotomy.  One  o'clock  was  the 
appointed  hour.  A\'hen  I  walked  into  the  college  cor- 
ridor, a  little  girl,  sitting  there  waiting,  commenced  to 
cry  and  screamed  so  she  could  be  heard  all  over  the 
building  and  out  in  the  street.  I  knew  that  this  w'as  the 
patient  without  being  told.  She  kept  up  this  yelling 
for  about  five  minutes  and  by  the  time  we  were  ready 
for  her  she  was  almost  frantic.  Not  a  very  favorable 
outlook  for  either  myself  or  somnoform  when  I  wished 
to  appear  to  good  advantage  before  the  students.  She 
had  to  be  dragged  into  the  operating-room  and  lifted 
on  the  table,  screaming  that  she  '"would  not  take  that 
stufi:',"  "she  would  not  open  her  mouth  and  have  her 
tonsils  out."    With  a  student  holding  each  leg  and  each 


284  General  Anesthetics  in  Dentistry. 

arm  and  another  holding-  or  steadying  her  head,  as  she 
opened  her  mouth  to  protest,  I  slipped  in  a  Whitehead 
mouth-prop.  With  her  head  held  firmly,  I  allowed 
enough  somnoform  to  enter  with  the  first  inhalation 
to  quiet  her  and  a  little  more  the  next  time,  then  about 
two  inhalations  with  all  air  excluded  and  Dr.  W — 
removed  the  left  tonsil,  then  the  right,  and  they  were 
both  out  at  least  30  seconds  before  she  moved  a  muscle 
or  changed  the  expression  of  her  face,  and  she  awoke 
good-natured  and  did  not  even  cry. 

Mental  and  Muscular  Excitement. — "Amongst  the 
common  causes  of  excitement  and  struggling  may  be 
mentioned :  the  employment  of  an  inhaler  whose  air- 
way is  or  has  become  restricted ;  undue  vapor  concen- 
tration ;  too  rapid  an  administration ;  and  handling  or 
necessarily  interfering  with  the  patient  whilst  semi- 
conscious." (Hewitt.)  When  proper  care  is  taken  and 
rational  methods  adopted,  struggling  and  excitement 
are  exceptional.  If  an  inhaler  is  employed,  in  which 
the  amount  of  air  is  restricted,  this  may  lead  to  a  vio- 
lent state  of  excitement  if  nitrous  oxid  is  being  admin- 
istered. Or,  if  too  much  anaesthetic  is  suddenly  in- 
haled, this  may  result  in  muscular  spasm,  leading  to 
asphyxial  conditions.  There  are  a  few  patients,  how- 
ever, who  become  excited,  boisterous  and  violent,  even 
though  every  precaution  known  is  taken  in  administer- 
ing the  anaesthetic.  These  conditions  are  met  with 
more  frequently  in  muscular  men,  and  especially  those 
addicted  to  strong  drink,  morphine,  chloral,  cocaine  or 
any  sedative  drug,  tobacco,  cigarettes,  etc.  These  pa- 
tients shout,  try  to  leave  the  chair,  swear,  and  show  a 


General  Ancosthetics  in  Dentistry.  285 

decided  disposition  to  become  pugilistic.  During  such 
struggling  if  nitrous  oxid  or  ether  is  being  used,  a 
restriction  of  air  is  indicated.  With  chloroform,  ethyl 
chloride  or  soninoform,  a  freer  admission  of  air  is  in- 
dicated. Closely  questioning  the  patient  will  usually 
unravel  the  mystery. 

A  vaudeville  singer,  some  weeks  since,  came  to  be 
anaesthetized  for  the  extraction  of  a  tooth.  I  selected 
somnoform.  From  the  first  inhalation  his  muscles 
commenced  to  contract.  His  fingers  doubled  back 
towards  his  wrist,  his  knees  were  drawn  up  in  close 
proximity  to  his  chin  and  all  of  his  muscles  were  vio- 
lently contracted.  Upon  inquiry,  afterwards,  it  devel- 
oped that  he  was  a  confirmed  cigarette  smoker,  a  verit- 
able fiend.  Once  or  twice  when  he  returned  to  the 
office  he  was  as  stupid  and  dull  as  if  under  the  influ- 
ence of  opium.  He  said  he  would  give  all  he  possessed 
to  be  cured.  Go  into  the  history  of  these  cases  and  a 
reason  nearly  always  develops. 

In  a  few  exceptional  cases,  anaesthetics  produce 
maniacal  or  delirous  symptoms.  These  are  more  com- 
mon to  nitrous  oxid  and  ether  than  to  ethyl  chloride, 
chloroform  and  somnoform. 

In  the  case  of  women  and  little  girls,  the  lady  as- 
sistant should  make  inquiry  as  to  how  long  it  has  been 
since  the  water  closet  was  visited,  and  you  can  do  the 
same  when  the  patient  is  a  male.  There  is  an  advan- 
tage in  having  the  bladder  emptied  just  before  anaes- 
thetizing a  patient  as  it  may  prevent  an  embarrassing 
and  decidedly  uncomfortable  situation.  In  an  anaes- 
thetic practice  of  more  than  thirty  years,  I  have  only 


i 


K 


286  General  Ancesthetics  in  Dentistry.    . 

had  four  cases  of  urination  during  the  anaesthesia  and 
no  case  of  defecation.  The  former  could  have  been 
avoided,  had  the  proper  inquiry  been  made  and  the 
suggestion  I  am  now  making  carried  out.  I  am  satis- 
fied that  I  have  prevented  many  such  occurrences  by 
taking  the  precaution  here  mentioned. 

The  dangers  that  may  arise  and  have  to  be  met  in 
administering  anaesthetics  may  be  classified  under  three 
heads,  namely : 

Respiratory  Arrest. 

Circulatory  Failure.    - 

Rupture  of  a  Blood  Vessel. 

The  most  important  of  these  is  respiratory  arrest. 
Most  of  the  mortalities  that  occur  during  anaesthesia 
are  primarily  respiratory  rather  than  circulatory.  Cir- 
culatory failure  is  nearly  always  of  secondary  origin, 
following  sooner  or  later  respiratory  arrest.     ' 

The  dental  sugeon  who  contemplates  employing 
anaesthetics  in  his  practice  should  make  a  study  of  Re- 
spiration, Circulation  and  Reflex  Action.  He  is  deal- 
ing with  these  conditions  every  moment  from  the  time 
his  patient  opens  the  office  door  till  the  eflfects  of  the 
anaesthetic  have  entirely  passed  away,  and  the  patient 
has  returned  to  the  normal.  You  will  pardon  me,  then, 
if  I  consider  these  subjects  at  some  length  and  find  it 
necessary  to  repeat  some  things  already  dwelt  upon  in 
speaking  of  the  various  anaesthetics,  individually,  in 
previous  lectures.  There  is  this  advantage  in  so  doing; 
namely,  it  places  within  the  scope  of  a  few  pages  data 
that  may  be   wanted   for  reference,   which   otherwise 


General  Anccsthctics  in  Dentistry.  287 

would  have  to  be  searched  out  in  fragments  from  a 
number  of  lectures. 

Respiratory  Arrest. 

In  health,  breathing  progresses  so  regularly  and 
continuously,  both  when  awake  and  asleep,  that  we 
seldom  give  it  a  thought.  The  air  we  breathe  passes 
through  the  nares  into  the  pharynx,  thence  into  the 
larynx  to  the  trachea  through  the  glottis,  then  through 
the  right  and  left  bronchi  into  small  tubes,  and  from 
these  into  the  air-cells  of  the  lungs  themselves. 

The  lungs  are  spungy  and  elastic,  gray  in  color, 
and  contain  about  8,000,000  air-cells.  It  is  said  that 
the  lungs  present  a  surface  120  times  greater  than 
that  of  the  entire  body.  In  these  cells  the  blood  comes 
in  contact  with  the  oxygen  of  the  air,  absorbs  it,  and 
gives  in  return  the  poisonous  gas,  carbon  dioxide. 

The  lungs  may  be  considered  as  a  bellows.  This 
bellows  may  be  perfect  in  construction  ;  yet,  like  any 
other  bellows,  docs  not  work  without  a  motive  power. 
The  motive  power  in  this  case  is  the  respiratory  center 
located  in  the  medulla  oblongata.  Both  of  these  or- 
gans may  be,  in  themselves,  in  excellent  condition, 
and  each  capable  of  performing  its  independent  func- 
tions, yet  they  are  dependent  one  upon  the  other.  The 
respiratory  center  may  give  the  signal  to  the  bellows 
to  begin  to  pump  and  actually  turn  on  the  ];i)\ver,  but 
if  the  respiratory  channel  be  obstructed  or  lung  expan- 
sion prevented,  the  command  cannot  be  oboyed.  On 
the  other  hand,  there  may  be  no  occlusion  or  stenosis 
of  the   air-channel,  and   the  bellows  be   in   excellent 


288  General  Ancesthetics  in  Dentistry. 

working  order,  but  it  can  not  start  if  the  respiratory 
center  does  not  furnish  the  motive  power  to  the  mus- 
cles of  respiration.  At  the  great  St.  Louis  exposition, 
the  day  arrived  when  all  the  details  had  been  com- 
pleted, and  the  machinery  was  ready  to  do  its  work, 
and  the  vast  afifair  held  its  breath,  as  it  were,  till 
Theodore  Roosevelt,  a  thousand  miles  away  in  Wash- 
ington, touched  a  button,  and  the  St.  Louis  exposition 
breathed  and  was  a  thing  of  life,  and  a  million  wheels 
sprang  into  action. 

In  administering  anaesthetics,  it  is  important  to 
proceed  in  so  quiet  and  orderly  a  manner  as,  on  the 
one  hand,  not  to  cause  any  interference  with  the 
bellows,  and,  on  the  other,  not  to  impair  or  unduly  dis- 
turb the  respiratory  center  in  the  brain.  When  the 
bellows  is  prevented  from  working  because  of  an  ob- 
structed respiratory  channel  or  lung  expansion,  it  is 
spoken  of  as  mechanical  arrest  of  breathing.  When 
the  respiratory  center  fails  to  respond,  it  is  spoken  of 
as  paralytic  arrest  of  breathing.  Mechanical  arrest 
of  breathing  may  be  a  matter  of  very  little  importance 
and  it  may  be  very  grave.  Paralytic  arrest  of  breath- 
ing is  always  a  serious  condition. 

Following  Hewitt  there  are  three  distinct  ways  in 
which  obstructive  arrest  of  breathing  may  take  place. 
It  may  result  (1)  from  occlusion  of  the  upper  air- 
passages,  such  occlusion  being  produced  either  by  (a) 
spasm,  (b)  swelling,  or  (c)  altered  position  of  parts 
within  or  about  the  upper  air-tract ;  (2)  from  the  pres- 
ence of  some  adventitious  substance  within  the  upper 


General  Ancesthetics  in  Dentistry.  289 

air-passages;  (3)  from  some  condition  which  directly 
prevents  lung  expansion. 

On  the  other  hand,  in  paralytic  cessation  of  breath- 
ing, respiration  simply  conies  to  a  standstill  as  the 
result  of  failure  of  nerve  energy.  This  failure  may  be 
(1)  toxic,  i.  e.,  from  an  overdose  of  the  anaesthetic 
upon  the  respiratory  center;  (2)  anaemic,  i.  e.,  from 
cerebral  anaemia  due  to  fall  of  blood  pressure ;  or  (3) 
reflex  (?),  i.  e.,  from  surgical  or  other  stimuli  inhibit- 
ing the  action  of  the  respiratory  center. 

Mechanical  obstruction  arising  from  spasm  of  the 
muscles  in  the  upper  air  passages  can  usually  be 
avoided  by  giving  attention  to  the  strength  of  the 
anaesthetic  vapor  employed.  The  vapor  in  the  begin- 
ning must  not  be  strong  enough  to  act  as  an  irritant. 
It  should  not  produce  coughing,  sneezing,  swallowing 
or  holding  of  the  breath.  It  should  be  sufficiently 
diluted  as  to  hardly  be  noticeable  by  the  patient  and 
its  strength  gradually  increased.  Thus  administered 
spasm  of  the  muscles  of  the  throat  will  not  occur. 

The  treatment  in  these  cases,  arising  from  too  con- 
centrated a  vapor  or  as  the  result  of  excluding  too 
much  air,  is  to  remove  the  inhaler  from  the  face  and 
allow  the  patient  to  breathe  all  air  till  normal  respira- 
tion is  restored,  then  adjust  the  inhaler  again,  admit- 
ting a  large  volume  of  air  and  very  little  of  the  anaes- 
thetic vapor,  thus  avoiding  irritation. 

A  thorough  examination  of  the  nares  and  throat 
should  be  made  to  ascertain  if  the  air-way  is  already 
partly  occluded  or  not.  If  such  an  examination  re- 
sults in  disclosing  the  presence  of  hypertrophied  tur- 


290  General  Ancesthetics  in  Dentistry. 

binated  bones,  nasal  polypi,  adenoid  vegetations  in 
the  upper  pharynx,  enlarged  tonsils,  or  any  other  ab- 
normal growths,  the  patient  is  a  poor  breather.  More 
care  must  be  exercised  in  the  case  of  such  a  patient 
than  if  the  air-way  contained  no  obstructions.  If  the 
choice  for  a  major  operation  was  to  be  made  between 
ether  and  chloroform,  other  things  being  equal,  chloro- 
form would  be  my  selection  for  this  patient.  Ether 
is  very  irritating  and  causes  secretion  of  mucus,  and 
in  these  conditions  large  quantities  of  mucus  are  al- 
wa)'s  present,  while  chloroform  administration  would 
not  be  productive  of  mucous  secretion.  If  the  opera- 
tion in  question  could  be  performed  under  nitrous  oxid 
or  somnoform  anaesthesia,  for  such  a  patient  as  de- 
scribed, I  would  select  somnoform.  Nitrous  oxid 
causes  an  enlargement  of  the  tongue  and  all  the  soft 
tissues  from  venous  engorgement.  The  mucus  mem- 
brane of  the  nares  would  be  swollen  from  engorge- 
ment of  blood,  so  would  the  already  enlarged,  turbi- 
nated bones,  adenoid  vegetations  and  tonsils,  and  we 
would  make  a  bad  condition  worse.  Somnoform  does 
not  cause  any  enlargement  of  these  tissues  and  would 
be  productive  of  a  more  comfortable,  a  safer  and  a 
profounder  anaesthesia. 

The  most  successful  treatment  in  these  cases  is 
prophylactic  treatment.  Prevent  the  occurrence  of 
the  condition  under  discussion  by  selecting  an  anaes- 
thetic agent  that  is  palliative  rather  than  productive  of 
the  condition  we  seek  to  avoid.  Judgment  and  com- 
mon sense  can  be  used  to  excellent  advantage  in  both 
selecting  and   administering   anaesthetics.      A    mouth- 


General  .Inccstlietics  in  Dentistry.  291 

prop  should  always  be  adjusted  when  an  anaesthetic 
is  to  be  administered  for  a  dental  operation.  With  the 
mouth  open,  the  tongue  can  l)e  observed  without  diffi- 
culty. If  the  i)atient  suddenly  makes  a  loud  snoring 
sound,  and  the  breathing  has  the  appearance  of  being 
interrupted,  take  the  inhaler  away  from  the  mouth 
and  examine  the  tongue  to  ascertain  if  it  has  been 
swallowed.  If  so,  grasp  it  with  a  tongue  forceps,  but, 
if  one  is  not  handy,  a  napkin  or  a  towel  will  do  as  well. 
Unless  you  have  a  dry  cloth  of  some  kind,  the  tongue 
will  be  found  too  slippery  to  hold  with  the  fingers.  If 
nothing  is  at  hand  with  which  to  grab  the  tongue,  it 
can  usually  be  pushed  to  one  side  until  the  assistant 
can  hand  you  a  napkin  or  an  instrument.  I  have  never 
experienced  any  difficulty  with  tongues  in  my  anaes- 
thetic work.  I  witnessed  an  interesting  case  at  Min- 
neapolis, during  a  meeting  of  the  State  Dental  Society, 
seven  years  ago.  A  young  man  was  exhibiting  and 
demonstrating  the  use  of  a  new  nitrous  oxid  appliance. 
As  no  one  seemed  sufficiently  interested  to  take  the 
anaesthetic,  every  few  minutes  he  would  secure  a  new 
audience  and  take  the  nitrous  oxid  himself.  Something 
happened  to  the  nasal  inhaler  so  it  did  not  work  satis- 
factorily, and,  after  rei)airing  it,  lie  slipped  it  on  his 
nose  to  test  its  efficiency.  He  was  alone  this  time. 
The  crowd  in  another  part  of  the  room  was  attracted 
by  a  terrible  crash,  and  we  went  over  in  the  direction 
of  thie  noise  to  see  what  had  happened.  We  found 
the  nitrous  oxid  salesman  on  the  floor,  his  face  a  deep 
l)urple.  He  was  snoring  loudly  and  one  of  the  dentists 
present    recognized   the   difficulty,   took   his   handker- 


292  General  Ancesthetics  in  Dentistry. 

chief  and  pulled  forward  his  tongue.  The  nasal  in- 
haler was  still  strapped  on  his  nose  and  I  went  over 
and  took  that  off.  He  remained  quiet  a  little  while  and 
got  up,  and  I  do  not  think  he  knew  that  anything  • 
unusual  had  happened.  He  made  the  following  re- 
mark which  greatly  amused  those  present :  "No  matter 
how  much  nitrous  oxid  I  inhale,  I  never  yet  have 
swallowed  my  tongue."  Had  this  man  been  in  the 
room  alone,  he  would  surely  have  died  from  asphyxia- 
tion because  his  tongue  had  been  swallowed,  thus  in- 
terfering with  respiration.  He  was  anaesthetized  to 
the  point  of  insensibility  and  the  nasal  inhaler  was 
strapped  on,  and  there  could  have  been  no  other  result. 


General  Anccsthetics  in  Dentistry.  293 


LECTURE  XXIII. 

Difficulties   and    Dangers    Incident   to    Administering 

General  Anaesthetics  in  Dental  Practice  and 

How  to  Meet  Them — Continued. 

The  presence  of  some  adventitious  or  foreign  mat- 
ter in  the  throat  is  the  condition  I  dread  most  in 
my  anaesthetic  work.  I  have  never  been  afraid  of 
spasm  arising  from  any  other  cause,  or  of  respiratory 
arrest  or  circulatory  failure  from  paralysis,  the  result 
of  an  overdose  of  anaesthetic, — none  of  these  things 
annoy  me  in  the  least,  but  I  am  apprehensive  lest  some 
time  I  may  have  trouble  from  blood  accumulating  in 
the  pharynx  or  larynx,  the  weight  and  presence  of 
which  might  reflexly  cause  paralysis  of  respiration. 
Avoidance  of  the  accumulation  of  blood  in  the  throat 
is  the  one  thing  about  which  I  am  more  careful,  if 
possible,  than  any  other  in  my  anaesthetic  practice. 

With  some  patients,  the  blood  clots  very  quickly 
and  I  have  often  seen  in  an  ordinary  nitrous  oxid  or 
somnoform  ancesthesia,  the  blood  become  almost  as 
solid  and  tenacious  as  a  hunk  of  liver.  Hewitt  men- 
tions removing  from  the  throat  a  conglomerated  mass 
of  clotted  blood  four  inches  long  in  an  extracting  case. 
Where  there  is  profuse  hemorrhage  at  the  time  of  ex- 
tracting under  nitrous  oxid  or  somnoform.  I  frec|uently 
cease  operating,  when  other  teeth  could  be  removed,  in 


294  General  Anccsthetics  in  Dentistry. 

order  to  take  care  of  the  rapidly  accumulating  blood. 
There  is  a  stage  in  both  nitrous  oxid  and  somnoform, 
with  some  patients,  in  which  there  is  a  contraction  of 
all  the  throat  muscles,  during  which  time  the  patient 
can  neither  spit  nor  swallow.  I  am  always  on  the  alert 
for  this  condition  in  cases  of  profuse  hemorrhage.  I 
do  not  throw  my  chair  back  very  far  even  when  oper- 
ating on  the  upper  teeth  and  I  am  very  careful  that 
little  or  no  blood  gets  in  the  throat  while  operating. 

My  assistant  is  over  or  under  the  socket  with  a 
napkin  almost  as  soon  as  I  have  the  tooth  or  teeth  out. 
We  use  the  ordinary  Johnson  &  Johnson  four-inch 
dental  napkins  for  this  purpose.  Two  or  three  of  these 
are  rolled  together  and  cut  in  two,  making  them  about 
two  inches  tall.  These  are  tied  about  the  center  with  a 
string  of  different  color  from  that  about  the  mouth- 
prop.  When  but  two  or  three  teeth  are  extracted  these 
are  crowded  immediately,  just  as  the  mouth-prop  is 
used,  over  or  under  the  extracted  tooth  or  teeth,  and 
allowed  to  remain  there  till  the  patient  is  perfectly  con- 
scious and  able  to  clear  and  rinse  the  mouth.  Then, 
just  before  removing  the  mouth-prop,  pull  these  nap- 
kins out  by  their  string.  Never  take  the  mouth-prop 
out  first.  Where  several  teeth  are  removed,  crumple 
the  napkins  in  the  hand  and  use  these  as  a  surgical 
sponge  till  the  patient  recovers.  If  blood  should  accu- 
mulate in  the  throat,  and  the  patient  does  not  swallow 
it  or  is  not  successful  in  coughing  it  up,  lean  him  for- 
ward, slap  him  on  the  back,  and  if  he  gets  cyanotic  and 
does  not  breathe,  hold  him  up  by  the  feet,  the  assistant 
slapping  the  back. 


General  Anccsthctics  in  Dentistry.  295 

If  the  patient  becomes  nauseated,  vomit  may  come 
up  into  pharynx  and  larynx  and  produce  exactly  the 
same  condition  as  accumulated  blood.  The  treatment  is 
the  same  as  that  for  the  former  condition. 

The  collection  of  particles  of  regurgitated  food  and 
mucus  in  the  larynx  produce  symptoms  sometimes  that 
are  mistaken  for  a  much  more  alarming  condition.  This, 
in  some  patients,  leads  to  labored  breathing,  cyanosis, 
feeble  pulse,  and  sometimes  pallor  is  mistaken  for 
surgical  shock  or  "syncope." 

Great  care  should  be  taken  that  extracted  teeth  or 
roots  do  not  find  their  way  into  the  throat.  Be  sure 
that  every  tooth  is  dislodged  from  the  forceps  and  is 
dropped  on  the  outside  of  the  mouth  before  extracting 
another.  Portions  of  enamel  often  fracture  and  fly  into 
the  throat,  and  roots  are  apt  to  do  the  same ;  for  this 
reason  one  must  be  exceedingly  careful  in  using  ele- 
vators when  extracting  under  an  anaesthetic.  Frag- 
ments of  teeth,  amalgam  fillings,  loose  crowns,  may 
easily  get  mixed  up  with  the  blood  and  saliva  and  pass 
into  the  throat.  If  these  are  swallowed,  but  little  harm 
arises,  but  it  becomes  a  serious  matter  when  they  find 
their  way  into  the  bronchi  or  lungs. 

*Tn  a  case  reported  by  Air.  Claremont,  some  frag- 
ments of  teeth  entered  the  larynx  during  chloroform 
anaesthesia.  \\'hen  the  patient  became  conscious,  after 
the  operation  was  over,  coughing  occurred,  and  a  com- 
plaint was  made  of  soreness  about  the  chest.  There 
were,  however,  at  the  time,  no  distinct  symptoms  of 
the  presence  of  the  fragments.    General  bronchitis  fol- 


296  General  Ancesthetics  in  Dentistry. 

lowed.  Subsequently,  the  fragments  were  coughed  up 
from  the  lungs  and  the  patient  made  a  good  recovery. 

"A  case  is  also  mentioned  in  the  Dublin  Medical 
and  Chemical  Journal,  in  which  the  roots  of  a  lower 
molar  entered  the  right  bronchus  after  extraction. 
Death  supervened  in  eleven  days. 

"Another  case  is  reported  in  the  Edinborough  Jour- 
nal, in  which  an  entire  lower  molar  entered  the  lung. 
It  was  coughed  up  on  the  eleventh  day  and  the  patient 
recovered. 

"In  the  British  Journal  of  Dental  Science,  January, 
1879,  a  case  is  related  in  which  a  large  amalgam  filling 
shot  from  a  tooth  during  extraction  under  nitrous  oxid, 
and  presumably  entered  the  larynx.  Fortunately  the 
patient  coughed  it  out  immediately  after  the  effects 
of  the  anaesthetic  had  passed  ofi. 

"In  a  case  referred  to  in  the  British  Medical  Journal, 
February,  1899,  an  extracted  tooth  entered  the  larynx 
during  nitrous  oxid  anaesthesia,  causing  extreme  cyan- 
osis. Subsequently  there  was  a  feeling  of  tightness  in 
the  throat,  aggravated  by  speaking  or  by  change  of 
posture.  No  breath  sounds  were  audible  over  the  left 
lung.  Death  took  place  in  twelve  days.  At  the  ne- 
cropsy the  tooth  was  found  in  the  left  bronchus. 

"A  case  has  lately  been  reported  to  the  author  in 
which  a  medical  man,  while  sponging  out  the  throat 
during  a  dental  operation  under  ether,  inadvertently 
pushed  an  extracted  tooth  backwards.  It  was  hoped 
that  the  patient  had  swallowed  the  tooth.  For  three 
weeks  she  sufifered  from  certain  chest  symptoms,  which 
she  ascribed  to  the  anaesthetic.     At  the  end  of  this 


General  Ancesthetics  in  Dentistry.  297 

time  the  tooth  was  coughed  up  and  no  further  trouble 
followed."  (Hewitt.) 

Respiratory  arrest,  the  result  of  paralysis  of  the 
respiratory  center  in  the  medulla  oblongata,  is  a  more 
serious  and  complicated  condition  than  the  variety  of 
respiratory  arrest  which  has  just  been  considered.  This 
condition  may  result  primarily  from  an  overdose  of  an- 
aesthetic, from  the  toxic  effect  of  the  drug,  or  cerebral 
anaemia  from  a  lowering  of  the  blood  pressure,  or  by 
reflex  action  resulting  in  inhibition. 

We  are  not  apt  to  encounter  respiratory  arrest,  the 
result  of  paralysis  of  the  respiratory  center,  in  dental 
practice  if  we  confine  ourselves  to  the  use  of  those 
anaesthetics  which  have  been  denominated  office  anaes- 
thetics; namely,  nitrous  oxid,  eth}I  chloride  and  som- 
noform.  We  would  hardly  expect  to  get  a  toxic  dose, 
if  these  agents  accumulated  in  the  system,  because  of 
the  brevity  of  their  action  and  their  rapid  elimination. 
We  would  not  expect  cerebral  anaemia  from  diminution 
of  blood  pressure,  because  the  three  anaesthetic  agents 
mentioned  are  all  stimulating  in  their  action,  and  pro- 
duce an  increased  blood  pressure.  Reflex  action  result- 
ing in  inhibition  usually  is  the  result  of  exposure  or 
handling  the  vital  organs,  severing  a  large  nerve  or  the 
like  in  major  operations.  If  this  condition  arose  at  all 
in  dental  practice,  it  would  proliably  be  the  result  of 
ether  or  chloroform  administration  and  if  you  adopt 
the  plan  recommended  in  these  lectures  of  having  a 
physician  always  administer  ether  or  chloroform  when 
indicated,  the  responsibility  would  not  be  yours  if  this 
condition    should    arise.      You    will    recall,    I    recom- 


298  General  Anccsthetics  in  Dentistry. 

mended,  that  the  anaesthetic  vapor  should  be  adminis- 
tered in  a  very  dilute  form  in  the  very  beginning  of  in- 
duction. If  this  suggestion  be  carried  out,  there  is 
very  little  danger  of  inhibition  by  reflex  action  in  the 
early  stages  of  anaesthesia. 

Respiratory  arrest,  the  result  of  paralysis  of  the 
respiratory  center,  usually  comes  on  gradually.  Res- 
piration slows  down ;  the  inspirations  are  not  so  deep 
and  become  lighter  and  more  shallow.  The  pupil  is 
usually  dilated ;  the  color  becomes  more  and  more 
dusky  or  pale  sometimes ;  the  eye-lids  contract ;  the 
pulse  becomes  lighter  and  more  feeble.  Respiration 
ceases,  but  the  heart  continues  its  action,  sometimes  for 
several  minutes.  When  this  condition  arises  from  a 
toxic  effect,  it  is  more  common  to  chloroform  than  any 
other  anaesthetic.  Chloroform  is  a  protoplasmic  poison. 

Respiratory  arrest  arising  from  paralysis  of  the  res- 
piratory center  depending  on  anaemia  is  the  result 
of  cardio-vascular  paralysis  which  in  turn  results  from 
an  overdose,  or  it  may  arise  as  the  result  of  anaemia  de- 
pending on  circulatory  failure,  or  from  lowering  blood 
pressure  from  an  upright  position. 

These  cases  demand  prompt  treatment.  If  the  con- 
dition is  observed  in  its  incipiency,  discontinue  the  an- 
aesthetic and  lower  the  patient,  if  in  the  sitting  pos- 
ture or  if  the  head  is  somewhat  elevated.  Satisfy  your- 
self by  examining  the  fauces  that  there  is  no  obstruc- 
tion to  the  passage  of  air  into  the  lungs  from  collection 
of  mucus  or  swallowing  of  the  tongue  or  regurgitated 
food  from  the  stomach.     If  no  mechanical  obstruction 


General  .liucstlietics  in  Dentistry.  2d\) 

is  present  and  respiration  docs  not  improve,  then  re- 
sort immediately  to  artificial  respiration. 

If  the  condition  under  consideration  should  arise  in 
a  dental  chair,  place  the  patient  as  quickly  as  possible 
on  the  floor.  Slip  a  pillow  or  a  cushion  under  the 
shoulders  to  elevate  them,  which  permits  the  head  to 
fall  backward  slightly. 

If  the  patient  is  on  a  surgical  table  slide  the  body 
along  till  the  neck  is  on  a  level  with  the  table  and  this 
position  will  allow  the  head  to  fall  over  the  end  of  the 
table. 

If  a  bed  is  being  substituted  for  a  surgical  table, 
place  the  patient  across  the  bed  so  the  head  will  drop 
backward  over  the  side  of  the  bed.  This  is  the  proper 
position  for  artificial  respiration  and  the  Sylvester 
method    is   considered   the   best. 

The  anaesthetist  should  stand  back  of  the  patient 
and  grab  each  arm  just  above  the  elbow.  Press  the 
arms  of  the  patient  firmly  and  steadily  against  the 
chest.  This  pressure  usually  causes  the  patient  to  ex- 
pire or  make  an  expiration.  If  not  successful,  a  cjuick 
pressure  forcibly  exerted  below  the  ribs  toward  the 
diaphragm  should  next  be  made.  Hold  the  arms  in 
this  position  for  about  two  seconds,  then  steatlih'  and 
evenly  draw  them  backward  as  far  as  possible  till  they 
are  in  line  with  the  extended  body.  The  object  of  this 
is  to  enlarge  the  capacity  of  the  chest,  the  pectoral 
muscles  raising  the  upper  ribs,  and  thu.^  to  produce  an 
inspiration.  The  arms  should  be  held  in  this  extended 
position  about  two  seconds.  Then  return  them  rhyth- 
mically to  the  side  and  press  the  chest  again.     This 


300  General  An(esthctics  in  Dentistry, 

should  be  continued  at  the  rate  of  fifteen  times  per 
minute.  Watch  carefully  for  a  return  of  respiration 
and  aid  it  till  it  is  normally  re-established.  Do  not 
become  discouraged.  Patients  are  sometimes  resusci- 
tated after  physicians  have  given  up  the  case  as  hope- 
less. A  very  prominent  Chicago  dentist  succeeded  in 
resuscitating  his  own  wife  two  hours  after  physicians 
had  pronounced  the  case  hopeless  and  taken  their  de- 
parture. Chloroform  was  the  anaesthetic  used  in  this 
case. 

In  the  Marshall  Hall  method  of  artificial  respiration 
the  patient  is  placed  face  downward  and  he  is  rolled 
to  his  side  gently,  then  back  again  about  fifteen  times 
per  minute.  When  in  the  prone  position  make  pres- 
sure on  the  back,  then  roll  to  the  side  again. 

There  are  other  methods  of  artificial  respiration, 
but  the  Sylvester  method  meets  the  requirements  bet- 
ter than  the  others. 

While  the  anaesthetist  is  busy  with  the  arm  manip- 
ulation the  tongue  should  be  grasped  with  a  forceps 
and  rhythmical  traction  made.  If  the  heart  is  beating, 
a  hypodermic  injection  of  strychnia,  1-20  of  a  grain, 
should  be  made  to  further  stimulate  the  heart's  action. 
Drugs,  however,  are  not  considered  of  much  avail  in 
this  form  of  respiratory  arrest  by  Hewitt  and  others. 

Circulatory  Failure. 

Circulatory  failure  is  a  condition  the  dental  surgeon 
is  not  apt  to  see  if  he  confines  himself  to  the  use  of 
nitrous  oxid,  somnoform  and  ethyl  chloride.  These 
agents  are  sometimes  productive  pf  respiratory  arrest, 


General  Ancesthetics  in  Dentistry.  301 

which,  of  course,  would  be  followed,  if  not  relieved,  by 
circulat(jry  failure.  Post-mortem  examinations  follow- 
ing death  from  both  nitrous  oxid  and  ethyl  chloride 
point  to  paralysis  of  the  respiration  as  the  cause  of 
death. 

There  is  nearly  always  impairment  of  breathini^ 
prior  to  circulatory  failure.  It  behooves  us  therefore 
always  to  carefully  watch  the  respiration  no  matter 
what  may  be  the  anaesthetic  agent  employed.  And  the 
pulse  should  be  watched  as  closely  as  the  respiration. 
It  is  an  easy  matter  in  administering  an  anaesthetic 
for  dental  purposes  to  keep  the  finger  of  the  left  hand 
on  the  temporal  artery  till  you  are  ready  to  operate  if 
the  operation  be  one  of  extraction,  and,  if  you  are  to 
operate  on  the  teeth,  the  assistant  can  be  taught  to 
hold  her  finger  on  the  artery  of  the  left  wrist  and 
inform  you  if  there  is  an  abnormality. 

The  treatment  of  circulatory  failure  is  first  to  dis- 
continue the  anaesthetic,  quickly  get  the  patient  in  a 
horizontal  position,  and  stimulate  the  breathing.  The 
respiration  must  be  taken  care  of  first  always,  if  there 
is  not  an  abundance  of  help  present,  the  one  thing 
above  all  others  to  do  first  is,  begin  artificial  respira- 
tion. "In  comparatively  minor  cases,  while  respiration 
is  still  continuing,  all  that  is  needed,  as  a  rule,  is  to  rub 
the  lips  briskly  and  to  assist  the  feeble  respiratory  ef- 
forts by  chest  compression.  These  measures  will  often 
ward  off  a  more  alarming  state,  the  pulse  and  color 
quickly  improving  in  response  to  this  simple  treat- 
ment."    (Hewitt.) 

In  the  graver  cases,  partial  or  complete  inversion  of 


302  General  Anesthetics  in  Dentistry. 

the  patient  was  first  advocated  by  Xealton.    Schuppert 
claims  to  have  saved  three  patients  by  inversion.    Oth-. 
ers  report  remarkable  success  accompanying  inversion. 
The  argument  is  that  respiratory  action  is  stimulated 
by  an  increased  cerebral  blood  supply. 

If  this  measure  fails,  massaging  the  muscles  over 
the  heart  may  be  resorted  to.  This  may  be  done  as  an 
adjunct  to  the  Sylvester  method  of  artificial  respira- 
tion. If  a  second  party  be  present,  the  muscles  over 
the  heart  may  be  massaged  at  the  time  that  artificial 
respiration  is  progressing. 

"Drugs  are  of  little,  if  any  service  in  cases  of  this 
class,  and  if  employed  should  be  administered,  not  by 
the  anaesthetist,  but  by  some  other  person  present.  The 
anaesthetist's  undivided  attention  must  be  devoted  to 
maintaining  efficient  artificial  respiration  and  a  proper 
posture.  To  commence  the  treatment  of  a  marked  case 
of  syncope  by  a  hypodermic  injection  of  ether  or 
brandy  is  not  only  useless  (seeing  that  the  circulation 
is  more  or  less  suspended)  but  dangerous,  in  that  such 
a  procedure  delays  the  application  of  artificial  respira- 
tion, the  remedial  measure  by  w^hich  the  elimination  of 
the  anaesthetic  and  aeration  of  the  blood  are  effected 
and  the  measure  of  all  others  which  is  most  likely  to 
increase  cardiac  action.  There  is,  of  course,  no  objec- 
tion to  the  employment,  by  some  other  person  than  the 
anaesthetist,  of  such  drugs  as  ammonia,  nitrate  of  amyl, 
strychnine,  or  cafifein ;  but  these  substances  should 
only  be  used  as  adjuncts,  and  in  the  manner  de- 
scribed."    (Hewitt.) 

Rhvthmical  compreSvsion  of  the  muscles  above  and 


General  .hucsthctics  in  Dentistry.  303 

around  the  heart  ma}'  be  accomplished  by  pressing  the 
right  thumb  between  the  sternum  and  the  apex  of  the 
heart  on  the  left  side,  the  left  hand  being  placed  over 
the  thorax  to  steady  the  body.  Compression  should  be 
made  about  seventy-five  times  per  minute. 

Slapping  the  face  with  towels  wet  with  cold  water 
stimulates  circulation  reflexly. 

In  the  earlier  stages  ammonia  nitrate  and  amyl 
nitrite  are  thought  by  some  to  be  beneficial.  The  amyl 
nitrite  is  put  up  in  glass  pearls  w^hich  are  crushed  on  a 
napkin  and  held  under  the  nose. 

A  nitroglycerine  tablet  of  the  strength  of  1-100 
placed  on  the  tongue  quickly  dissolves. 

In  regard  to  the  treatment  of  circulatory  failure  due 
to  surgical  procedure,  there  is  a  difference  of  opinion 
among  the  authorities.  Crile  and  Mummery  agree  that 
strychnia  is  useless  in  these  cases.  Crile  found  by 
experiment  that  repeated  injection  of  strychnia  in 
healthy  animals  produced  shock.  Only  in  animals 
with  mild  degrees  of  shock  was  strychnia  of  service ; 
and,  as  soon  as  the  effect  passed  off,  these  suffered  a 
deeper  degree  of  shock.  Crile  also  makes  the  claim  that 
in  the  intra-venous  injection  of  alcohol  there  was  gen- 
erally a  fall  in  the  blood  pressure,  and,  in  an  animal 
suffering  from  shock,  it  caused  a  further  decrease  in 
blood  pressure.  IMummery  verified  the  findings  of 
Crile  by  tests  made  with  the  sphygmomanometer. 
Crile  has  invented  a  pneumatic  suit  by  the  use  of  which 
he  succeeds  in  raising  the  blood  pressure  or  prevent- 
ing its  fall. 

In  case  of  cessation  of  breathing,  no  time  must  be 


304  General  Anccsthetics  in  Dentistry. 

lost  in  removing"  all  obstacles  to  lung  expansion.  Of 
the  thirty-five  nitrous  oxid  deaths  that  have  been  re- 
ported, several  are  known  to  have  been  caused  by  tight 
corsets.  All  tight  clothing  and  bands  must  be  removed 
as  quickly  as  possible,  no  time  is  to  be  lost.  A  combi- 
nation of  oxygen  85  per  cent,  and  carbon  dioxid  15 
per  cent,  is  kept  constantly  on  hand  at  the  Florentine 
University,  Mosso  believing  this  combination  to  be 
superior  to  anything  known  for  resuscitation. 

Respiratory  spasm  under  nitrous  oxid,  somnoform 
and  ether  is  not  as  dangerous  as  the  same  condition 
occurring  during  chloroform  anaesthesia,  because  chlo- 
roform is  a  protoplasmic  poison,  and  this  poison  ac- 
cumulating in  the  system  is  an  added  feature  to  the 
danger.  If  spasm  does  not  subside  upon  loosening  the 
clothing,  the  tongue  should  be  pulled  forward,  any 
mucus  in  the  throat  removed,  the  artificial  respiration 
commenced,  the  patient  being  placed  on  a  table  or  the 
floor  with  the  shoulders  slightly  elevated  and  the  head 
dropped  backward. 

Both  in  respiratory  arrest  and  circulatory  depres- 
sion admission  of  air  to  the  lungs  is  worth  more  than 
all  the  drugs  in  the  pharmacopoeia.  In  an  experience 
of  more  than  thirty  years  with  anaesthetics  in  den- 
tal practice,  the  writer  has  never  found  it  necessary 
to  use  the  hypodermic  syringe  or  resort  to  the  use  of 
drugs  or  stimulants  on  account  of  either  circulatory 
depression  or  respiratory  arrest.  He  recognizes  the 
importance,  however,  of  being  prepared  for  an  emer- 
gency, and  the  man  who  is  administering  an  anaes- 
thetic, whether  physician  or  dentist,  should  have  every 


General  .liiccsthctics  in  Dentistry.  305 

agent  and  remedy  at  hand  that  might  be  needed  in  case 
an  accident  should  happen.  With  this  end  in  view,  the 
writer  advises  that  you  provide  yourself  with,  and  have 
within  reach,  the  following: 

1.  A  supply  of  mouth-props. 

2.  One    or    more    tongue    depressors    or    tongue 
guards. 

3.  A  tongue  forceps. 

4.  A  hypodermic  syringe  and  needles. 

5.  Hypodermic  tablets  of  strychnia  sulphate,  1-20 
grain. 

6.  Hypodermic    tablets    of    nitro-glycerine,    1-100 
grain. 

7.  Aromatic  spirits  of  anmionia. 

8.  Vaporole  Aromatic  Ammonia. 

9.  Brandy. 

10.  Amyl  nitrite  pearls. 

11.  Adrenalin,  1-20,000. 


INDEX. 

Page 

Anesthesia — 

Accidents  during,  legal  aspect 18-20 

Asphyxia!   theory    107 

Bad  effects   of." 32 

Blood  accunuilating  in  throat   in 293 

Carbon    dioxid    in 156-157 

Care  of  patient  after 219-260 

Circulatory   failure 300-303-304 

Deaths  during   40-97-134-140 

Dental  uses  of 25-28-29-30-161 

Difficult   148-228 

Heart  Disease    32-33 

Preparation   for    62 

Psychical    element    in 39 

Kespiration  in    34-131 

Safety  of   31-35-47-48 

Stages  of   126-128-131-133 

Suggestion   in    268 

Teeth   in   throat 295 

Anesthetics — 

Accidents  and  dangers,  treatment  of 279-293 

Afferent  nerves,  stimulation  of 56 

Care  of  patient  after 219-260 

Chairs  in  administration  of 89 

Chloroform    243-257 

Circulatory  arrest,  treatment  of 293 

Deaths  during   40-97-134-140 

Difficulties    and   dangers 274-293 

Ether    sulphuric    257 

Ethyl    chloride    169 

Exc'itemcnt  in   248 

History  of   13-14-103-104-105-106 

Nitrous  oxid    103 

Nitrous  oxid  and  oxygen 143 

Preparation  for    62 

Psychical  element  in  administration  of 39-68 

Respiratory  arrest,  treatment  of 293 

Resuscitation,  methods   of 298-299-300 

Right    to    administer 15-17 

Somnof  orm     1 79 

Suggestion    in    administering 74-268 

Analgesia — 

CMdoroform  243-249-250-276 

Dental  Operations  under 161-163-167-225-232-243-249 

Nitrous  oxid  in 161-163 

Nitrous  oxid  and  oxygen  in 1G2-163-164-165-166 

307 


308  Index. 

Somnof oim 225-232 

Stage  of 276 

Andrews — 

Apparatus 144 

DeFord  nitrous  oxid  aud  oxygen  inhaler 166-166A 

DeFord  somnoform  appliance .  .192-192A 

Gregg  nitrous  oxid  inhaler 164 

Gwathmey — ether  and   chloroform 160 

Lennox   stand    150  151 

McKesson  nitrous  oxid  and  oxygen  appliance 112-114 

Kew  Clark  nitrous  oxid  and  oxygen 109-110 

Ohio  monovalve 116-118 

Portable  stand   117 

Stark  somnoform  inhaler 188-189 

Teter,  improved   108-162-163 

Asphyxia — 

Dangerous    282 

Demarquay   experiment    143 

Ethyl   chloride    173 

Heart  in  death  from 111-132-133-134-137 

Muscular  spasm  leads  to 284 

Nitrous  oxid   107 

Prevention  of    151-157-282-295 

Somnoform    184 

Assistant — 

Duties  of   80-84-85-88-121-285 

Brunton,  T.  Lauder 33-39-54-58-64 

Buxton,  Dudley  W 46-58-133-201 

Chloroform — 

Administration   of    250-273 

Analgesia   243-249-250-276 

Causes  of  death  in  early  stage 56 

Contra — indicated  in  35 

Dangers  from   273 

Dangerous  symptoms  in 273 

Deaths  m  dental  chairs 65 

Dental   uses   of 28-243-249-257 

Fatalities     37-55-259 

Hewett  method   27-243 

Stages    of    276 

Tests  of  273 

Eesuseitation  methods   298-304 

Christian  Science 69-72 

Crile   301-303 

Davy,  Sik  Humphrey 106 

DeF'ord,  Jessie  R 167 

Nitrous  oxid  and  oxygen  inhaler 165 

Somnoform    appliance    191-238 

Deaths,   caused  by 96-134 

Chloroform    56-101 

Ethyl    chloride    301 

Extracting  tooth 53 

jSitrous   oxid    111-135 

During  anajsthesia    40-97-134-140 


Index.  309 

Ethyl  Chloride — 

Admiuistration   of    174 

Alcoholics  ill   125 

Cyanosis    under    176 

Death  rate   94 

Deaths   under    173 

History  of   1G7 

Indications  for    173 

Nausea   in    174 

Popuhir     100 

Safety  of   172 

Ether,  Sulphuric — 

Administration   of    256 

Choice  of   262 

Death  rate  in 94 

Dental  office    257 

Discovery  of    264 

Resuscitation  in 298-299-300-301-302-303-304 

Extraction — 

Chair  for   91 

Fear  of    52 

Hypnotism  under   74 

Chloroform  in   274 

Fatigue — 

Definition  of   67 

Psychical    elements    74 

Relation   to   shock 23 

Fear — 

Cause  of  siiock 51-62-55-57 

GwATHMEY,  James  T 143 

Appliance     103 

Hakuis,  Chapin  a 15 

Heart — 

Action  under  carbon  dioxid 158 

Arrest  of   300 

Ethyl  chloride,  action  of 169 

Fatty   degeneration   of 

In  death  from  nitrous  oxid 111-301 

Lesions  in  antestlietics 32-33-37 

Somnoform,   action   under 212-213-218 

Henderson,  Yandell   156-157-158-159 

Hewett,  a.  C 28-243-247 

Hewitt,   Fred'k   W.  .  .50-102-107-109-110-111-133-134135-139-144 

265-276-301-302 

Hetrick,  Frank  O 234 

Holmes,  Oliver  Wendell 106 

Hyderabad  Commission   33-34 

Julliard    94 

Levi  Kttord   1 56 

Luke,  Thomas  D 31-32-94-172-265 

Macaw,  Alice  46-267  269 

Mayo  Clinic    269 

McKesson   112-159 


310  Index. 

Morton    14-264 

Mosso  156-304 

Nausea — 

Causes   of    62-63-89-177-206 

Ether  sulph 258 

Nitrous  oxid  in 203-206 

Somnof orm   in    ' 202 

Nevius,   Laird  W. — Frontispiece 98-104 

Nitrous  Oxid — 

Administration  of  . 120 

Alcoholics  in   176 

Available  anassthesia   132 

How  made   113 

Nausea    203-206 

Pulse  in   130 

Eespiration  in 127 

Stages  of 127 

Stertor   in    131 

Tongue  in   135 

Warmed    118 

Nitrous  Oxid  and  Oxycen 143 

Administration  of    147 

Air    admixture    in 146 

Apparatus   ..  .107-109-110-112-116-117-150-162-163-164-165-166 

166A-188-189-238 

Asphyxiating  qualities  of ■ Ill 

Carbon   dioxid   in 156-157-158-159 

Danger  symptoms  in 134 

Deaths  under   111-135 

Dental  uses   161 

Discovery  of   104 

Dreams  during '. 129-142 

Extraction  under   121 

Mouth  prop  in 266 

Safety  of 156 

Stages  of 154 

OCHSNER     31-37 

Priestly    143 

Prinz  Hermann 94 

Pulse — 

Nitrous   oxid    130-132 

Nitrous  oxid  and  oxygen 155 

Somnoform     195-196 

Pupil — 

Action  under  ethyl  chloride 176 

Action  under  nitrous  oxid 130-133 

Action  under  nitrous  oxid  and  oxygen.. 155 

Eespiration — 

Arrest  of    280-296-297-298 

Artificial  respiration   299-300-304 

Carbon   dioxid    in 156-157-158-159 

Care   in    39 

Corset   in    59 

Ethyl  chloride  in 172-ir6 


Index.  311 

Hall  method  of  artificiiil 299 

Impedinieuts   to    134 

Paralysis  of 301 

Restoratives    in    ;>()2-304 

Soninoform     199 

Sylvester  artificial    299-300-302 

Kesuscitation — 

Methods   of    298-299-300-301-302-304 

ElCHARDSON      32 

EOLLAND     14-179 

schofield    54 

Shock — 

Causes  of   22  51  -55-63 

Circulatory     50 

Classification  of 51 

Composite    50 

Deaths  from    , 52-53-101 

Definition  of    50-51 

Psychical  elements   in 51 

Respiratory     50 

SOMNOFORM — 

Administration    of    207-210 

Air  in  administration  of 210 

Alcoholics   under    214-228-229 

Analgesia   with    225-232 

Dreams  under    221 

Extraction   under    212  213 

Inhaler,  DeFord   192-lfl2A 

Inhaler,  Stark   188-189 

Mucous  membrane,  effect  on 202 

Nausea     1 82-202-203-20(5-216 

Neurotics  in 176 

Operations   233 

Over-ana>sthization    .203-218 

Period  available   181 

Plethorics   under    210-213 

Respiration  in 199 

Safety    of    182 

Spasm — 

Causes     61 

Clonic    133-144 

Conjunctival  reflex   130-133 

Deaths    due   to 96 

Effects   duriufj  ana'sthesia 60 

Larvngial  reflex    202 

Of  irlottis 59 

Simpson,  Sir  .Tames   Y 56-270 

Stertorous  BuEATiiiNr,    131 

Success — 

Elements  of '^9 

SUOGESTION — 

As  an  aid  in  inducing  anspsthesia 82-268 

Teter,   Ciias.   K 98-107-147-162 


313  Index. 

Thorpe,  Burtox  Lee 104-106 

Wells,    Horace — Portrait,    frontispiece 14-1U4-106 

Women — 

As  ana?sthetists  46 

Clothing,   arrangement   of,   for   antesthesia .59-279-304 


Date  Due 

M     II  ^ 

iKIh^ 

-Apr  2 8 

1941 

■ 

f) 

J 


